Structural Validation of the Manchester-Oxford Foot Questionnaire (MOxFQ) for use in Foot and Ankle Surgery

Category: Other Introduction/Purpose: The Manchester-Oxford Foot Questionnaire (MOxFQ) is a condition specific patient reported outcome measure (PROM) for foot and ankle surgery. It consists of 16 items across three subscales measuring distinct, but related traits: walking/standing ability, pain, and social interaction. Although it is the most used foot and ankle PROM in the UK, initial MOxFQ validation involved analysis of only 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual’s response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ. Methods: This was a single-centre, prospective cohort study involving 6640 patients (mean age 52, range 10-90 years) presenting with a wide range of foot and ankle pathologies between 2013 and 2021. Firstly, to assess whether the MOxFQ responses vary by anatomical region of foot and ankle disease, we performed multi-group confirmatory factor analysis. Secondly, to assess the structural validity of the subscale items, exploratory and confirmatory factor analyses were performed. Results: Measurement invariance by pathology was confirmed suggesting the same model can be used across all foot and ankle anatomical regions. Exploratory factor analysis demonstrated a 2-3 factor model, and suggested that item 13 (inability to carry out my work/everyday activities) and item 14 (inability to undertake social/recreational activities) loaded more positively onto the walking/standing subscale than their original social interaction subscale. Conclusion: This large-cohort study supports the current widespread use of the MOxFQ across a broad range of foot and ankle pathologies. Items 13 and 14 might be better moved from the “social interaction” to the “walking/standing” subscale and this may have future implications for deriving/analysing subscale scores

Assessing the Appropriateness of Repeat MRI Scan Requests Within a Foot and Ankle Department

Category: Other Introduction/Purpose: With diagnostic resources often in great demand, it is important to ensure clinicians request investigations appropriately. Unnecessary radiological investigations are costly and delay patient care. This study aimed to assess the incidence and appropriateness of repeat MRI scans being requested in a single foot and ankle unit, to identify areas which can be improved. Methods: This was a retrospective analysis of 1322 scans between October-2019 to October-2022. We included all patients who had a diagnostic MRI scan requested after being assessed in our foot-and-ankle clinics. Assessments were made on the proportion of repeat scans, the seniority of requester, the indications put forward for the repeat scan, the modality of patient assessment (telephone vs face-to-face appointment), and the impact on patient management. A scan was considered a repeat, if the same anatomical location was scanned within a 3-year period. Scans were deemed appropriate if they were: part of a clinical trial, for tumour/infection/stress-fracture monitoring, for new trauma, pre-operative planning, following agreement in MDT discussions, or following significant changes in clinical symptoms. We expected that scans should ideally only be requested where the result is expected to influence management and that a scan should not be repeated without evidence of change in clinical symptoms (unless for monitoring). Results: Over the 3-year period, 6.5% of MRI scans performed were considered repeat scans. The average time between initial and repeat scans was 13.1±8.6months (range 1-33 months). 88% of patients had only one repeat scan. The majority(58%) of repeat scans were requested by non-senior clinicians. In total, 47/85(55%) scans were deemed appropriate. 75% of the patients in this cohort had been assessed face-to-face. Twenty of these scans were repeated for significant change in clinical symptoms and 50% meaningfully influenced management plans. Conversely, 38/85(45%) repeat scans did not have strong clinical indications. The majority(80%) of these were requested by non- senior clinicians and 50% were requested after a telephone review. From the scans requested by the non-senior clinicians, none(0%) had a meaningfully influence on patients’ management plans. Conclusion: This study highlights that although repeat MRI scans were not common, they seldom influenced patient management unless there was a meaningful change in patient symptoms. MRI scans were more likely to influence management when initiated by senior clinicians and following a face-to-face assessment. In order to streamline patient care and reduce unnecessary investigations we propose a protocol to guide the requesting of repeat scans. This protocol includes identifying significant symptomatic change, in-person review, and senior clinician or multi-disciplinary input when a repeat scan is being considered

One Year Outcomes of the H-AMIC Procedure for Osteochondral Lesions of the Talus

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Osteochondral lesions of the talus (OLTs) present a challenging clinical problem. Hyaluronic acid assisted autologous membrane-induced chondrogenesis (H-AMIC) is a technique where a polyglycolic acid and hyaluronin membrane scaffold (Chondrotissue ® ) is affixed over an area of talar bone marrow stimulation. Our study aims to assess the efficacy of this technique. Methods: We undertook a prospective study on consecutive adult patients at our unit who had H-AMIC procedures between January 2020 and November 2021 to treat single, symptomatic OLTs, >1.5cm 2 , refractory to previous management. Data was collected on patient reported outcomes (MOxFQ, EQ5D, satisfaction), ankle range of movement, and complications at 1-year post-surgery. Fifteen patients were included in this study with a mean age of 33.8±20.9 years. Mean duration of symptoms was 7.9±5.2 years, with a mean of 1.5 previous procedures (range 0 to 3). All patients had osteotomies to gain access to the OLT (13 medial malleolar, 2 fibular). Results: Mean improvements greater than the minimum clinically important difference (MCID) were seen in MOxFQ-Pain (61.7±26.1 to 48.3±21.8, p=0.112), MOxFQ-Walking (64.6±21.8 to 46.6±23.9, p=0.067), MOxFQ-Social (63.67±22.5 to 41.8±29.2, p=0.055), although none reached statistical significance. No difference was seen in EQ5D. Overall improvements were seen in MOxFQ-Pain in 58.3%, MOxFQ-Walking in 75%, and MOxFQ-Social in 83.3% of patients. Overall, 11 patients (73.3%) were satisfied with the procedure. Patients displayed improvement in plantarflexion from 33.1±5.5 to 42.0±7.9 degrees (p=0.002) and no change to dorsiflexion. There were no complications. Conclusion: The H-AMIC procedure is a promising and safe option for larger osteochondral lesions of the talus. Early results suggest improved range of motion despite osteotomy and clinically (but not statistically) significant improvement in function in a group of patients with longstanding symptoms and previous failed surgery. Larger, adequately powered cohorts may establish statistical efficacy of this technique compared with alternative techniques

Talar Neck Rotation Angle in Adults with Clubfoot Deformity: Observed Values and Intra- and Inter- Observer Reliability using Weightbearing CT

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Adults presenting with symptomatic clubfoot represent a challenging cohort of patients. An appreciation of the location and degree of deformities is essential for management. Talar anatomy is often abnormal with varus within the talar neck, however, there are few reproducible methods which quantify talar neck deformity in adults. We describe a technique of assessing talar neck deformity, and report on observed values and intra- / inter-observer reliability. Methods: This was a single-centre, retrospective study including 96 feet from 56 adult patients with clubfeet (82 feet had clubfoot deformity, 14 were normal). Mean age was 34.3±16.9 years and 31 (55.3%) were male. Weight-bearing CT scans captured as part of routine clinical care were analysed. Image reformats were oriented parallel to the long axis of the talus in the sagittal plane. In the corresponding axial plane two lines were drawn (on separate slices): 1) a line perpendicular to the intermalleolar axis, 2) a line connecting the midpoints of the talar head and narrowest part of the talar neck. The talar neck rotation angle (TNR angle) was the angle formed between these lines. Intraclass correlation coefficients (ICC) were performed for intra- and inter-observer reliability. Results: Mean TNR angle in clubfeet was 27.6±12.2 degrees (95%CI = 25.0 to 30.2 degrees). Mean TNR angle in normal feet was 18.7±5.1 degrees (95%CI = 16.0 to 21.4 degrees) (p < 0.001). The ICC for clubfeet was 0.944 (95%CI = 0.913 to 0.964) for intra- observer agreement, and 0.896 (95%CI = 0.837 to 0.932) for inter-observer agreement. Conclusion: This measurement technique demonstrated excellent intra- and inter-observer agreement. It also demonstrated that compared to normal feet, clubfeet had about 9 degrees of increased varus angulation of the talar neck. This technique and data may be used for future research into clubfoot deformity and in planning treatment