TENDINopathy Severity Assessment - Achilles (TENDINS-A):Development and Content Validity Assessment of a New Patient-Reported Outcome Measure for Achilles Tendinopathy

OBJECTIVE: To develop a new patient-reported outcome measure (PROM) assessing TENDINopathy Severity of the Achilles (TENDINS-Achilles) and evaluate its content validity. DESIGN: Mixed-methods, modified Delphi. METHODS: We performed 1 round of semistructured one-on-one interview responses with professionals and patients, for initial item generation. This was followed by 1 round of survey responses for professionals and a final round of semistructured one-on-one interviews with patients. The work culminated in a PROM to quantify Achilles tendinopathy severity under the core health domain of disability. Participants identified 3 subdomains contributing to the severity of disability of Achilles tendinopathy: pain, symptoms, and functional capacity. RESULTS: All 8 patient participants invited to participate were enrolled. Forty professional participants (50% women, six different continents) were invited to participate and 30 were enrolled (75% response rate). Therefore, a total of 30 professionals and 8 patients were included within this study. Following 3 rounds of qualitative or quantitative feedback, this study has established the content validity of TENDINS-A (good relevance, comprehensibility, and comprehensiveness) as a new PROM to assess the severity of Achilles tendinopathy, which assesses aspects of pain, symptoms, and functional capacity. CONCLUSION: TENDINS-A has established content validity and is appropriate for use with clinical and research populations. We recommend users interpret TENDINS-A results cautiously, until further testing evaluates the most appropriate scoring scale, reliability, construct validity, criterion validity, and responsiveness of TENDINS-A. Until these psychometric properties are established, we suggest using TENDINS-A alongside existing tools. J Orthop Sports Phys Ther 2023;53(11):1-16. Epub: 24 August 2023. doi:10.2519/jospt.2023.11964.</p

Patient Perceptions of Achilles Tendon Rupture

Category: Sports Introduction/Purpose: The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopaedic surgeons. However, patient perceptions of ATRs are unclear. Many patients understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. Many patients may assume that an ATR necessitates surgical treatment or that surgical treatment is “better” because that is how professional athletes are often treated. These ideas may be related to a patient’s health literacy. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with health literacy and the education level of the patient. Methods: Patients presenting to an academic orthopaedic foot and ankle clinic with a complaint of Achilles tendon injury were asked to fill out a demographic form, the LiMP (Literacy in Musculoskeletal Problems) survey to assess musculoskeletal health literacy, and a 22 question survey on ATRs designed to assess patients knowledge and perception of ATRs that was modelled after a similar survey done for meniscal injuries. Results: Twenty-nine patients were surveyed with a mean age of 45 years. 62% of respondents noted that they had little knowledge of the Achilles, with the remaining 38% saying that their knowledge of the Achilles was moderate to considerable. 14% of those surveyed were employed in healthcare. The mean LiMP score was 4.91 (out of 9, mean in general population in another study was 4.68). 70% of patients replied that surgery alone or in combination with physical therapy was the most appropriate treatment for an ATR. Only 11% of patients responded that physical therapy with some immobilization was sufficient. Conclusion: Patient perception of ATR treatment appears to be biased to some degree towards surgery. In an educated patient group that scored well in terms of health literacy, a majority of patients felt that surgical treatment was most appropriate. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive

Evidence Versus Practice: Operative Treatment Preferences in Hallux Valgus

Background: There is substantial variability in the operative treatment of hallux valgus despite the existence of high quality evidence to guide treatment decisions. The purpose of this study was to determine the current trends in the treatment of mild, moderate, and severe hallux valgus and if greater degrees of consensus correlate with the presence of higher-level evidence. Methods: Members of the American Orthopaedic Foot & Ankle Society completed a 14-item survey. A total of 131 (14%) of 922 members completed the survey. Three cases representing 3 stages of HV were presented, and respondents selected their preferred treatment. Preferred forms of proximal and distal metatarsal osteotomies, as well as mode of fixation for each, were inquired. Results: In the treatment of mild hallux valgus without second metatarsalgia, 80% of those surveyed chose a distal metatarsal osteotomy, while, if second metatarsalgia was present, 56% chose a distal metatarsal osteotomy with a second metatarsal-shortening osteotomy. In the treatment of moderate hallux valgus, there was generally less consensus, while, in the treatment of severe hallux valgus, a majority of those surveyed chose a Lapidus procedure, with the addition of a second metatarsal-shortening osteotomy in the presence of second metatarsalgia. The most popular distal and proximal metatarsal osteotomies, respectively, were chevron osteotomy (80%) and opening wedge osteotomy (33%). The presence of Level I evidence did not significantly correlate with higher degrees of consensus. Conclusion: Despite the existence of high-quality evidence supporting the use of certain procedures in the treatment of HV, there exists an apparent lack of consensus among surgeons about the choice of surgical procedures. Moreover, higher-level evidence was not correlated with greater consensus in hallux valgus. Level of Evidence: Level II

Performance Function Tests in Healthy Athletes

Category: Sports Introduction/Purpose: A challenge for physicians is determining when an injured athlete is ready to return to competition. While a wide variety of ankle strength and fitness tests have been described, there are no norms or minimum performance thresholds for any of them. In this study, healthy athletes were given a series of functional tests to complete. We propose that there will be a minimum performance level for each of the tests that all athletes can complete. We also propose, for tests which assess the right and left legs independently, that performance of the right leg will consistently be within 10% of the left. Finally, we propose that performance on one of the functional tests will be predictive of function on all of the tests. Methods: Healthy college athletes were put through a testing protocol, beginning with simple range of motion assessment and progressing through a series of functional ankle tests of increasing difficulty. The athlete began with the dorsiflexion lunge test, and then progressed to single leg heel raising, single leg hopping, side hopping, front-back hopping, functional hop test, and finally 180 degree rotational jump. Right and left legs were recorded separately for the first five tests. For each test, means, ranges, and standard deviations were calculated. Results: Eighty-one athletes (male and female from different sports) completed the protocol; no athlete was unable to finish the testing sequence. There was a wide variation in performance ability between athletes; the standard deviation for any of the individual tests was too high to determine a minimum threshold of normal performance. However, when comparing right to left leg in any one athlete, the difference in performance testing was always less than 10%. Furthermore, performance on any of the hopping tests was predictive of performance on all of them. Conclusion: Ideally, an athlete could be deemed ready to return to sports activity if he or she performed above a certain threshold on a performance test. Unfortunately, athletes had such a wide range of performance that it is not possible to define a minimum threshold for any of these tests. However, right and left leg performance was always within 10% of each other. For an athlete with a single leg injury, we propose that performance on a functional hopping test less than 10% different from the uninjured leg should be the standard

Spinopelvic Dissociation: A Systematic Review and Meta-analysis.

INTRODUCTION Spinopelvic dissociation is a rare type of injury which occurs in approximately 2.9% of pelvic disruptions and correlates with high-energy trauma.The purpose of this study was to systematically evaluate the incidence, demographics, treatment, clinical outcome, and complication rate associated with these injuries. METHODS A literature review on Medline, PubMed, and Google was performed. Overall, 216 abstracts were reviewed in English, German, and French, of which 50 articles were included. RESULTS Within the 50 studies, 19 publications were case reports and 16 were case series with low-level evidence. Overall, 379 patients with spinopelvic dissociation were identified at a mean age of 31.6 ± 11.6 years and an injury severity score of 23.1 ± 3.8 between 1969 and 2018. Most cases were related to fall from heights (55.7%), followed by road accidents (28.5%). Two hundred fifty-eight patients (68.1%) showed neurologic impairment at initial presentation, which improved in 65.1% after surgery. The treatment of choice was surgery in 93.1% of cases with triangular fixation in 68.8%. Regardless of the technique, the healing/fusion rate was 100% with a complication rate of 29.9% (n = 96/321). CONCLUSION Spinopelvic dissociation is a rare type of injury with limited data in the literature. Based on our review, it is possible that a streamlined, evidence-based algorithm may improve care for these difficult patients. LEVEL OF EVIDENCE II STUDY DESIGN:: Systematic Review

Results of Functional Treatment of Epi-Metaphyseal Fractures of the Base of the Fifth Metatarsal

Background: Fractures of the fifth metatarsal base (5th MT) are common foot injuries, but their treatment remains a subject of debate. The aim was to assess the midterm outcome of functionally treated epi-metaphyseal fractures (Lawrence and Botte types I and II) of the 5th MT. Methods: This study was a longitudinal retrospective database study with prospective follow-up. Included were all patients with an acute, isolated fracture to the 5th MT base (types I and II). All patients were treated functionally: weightbearing as tolerated without immobilization. Fracture types and fracture characteristics (displacement 2 mm, articular involvement, number of fragments) were assessed retrospectively. Patient-reported outcome measures (PROMs) including the visual analog scale for foot and ankle (VAS FA) and the quality-of-life score (QoL) SF-12 were collected prospectively at 2- and 5-year follow-up. Out of 95 patients, 43 patients (45%) were included with a median follow-up of 5.7 (1.5) years. Results: For both the VAS FA and SF-12, excellent scores were observed. For 30 patients (77%), longitudinal 2- and 5-year follow-up was available. No significant longitudinal changes could be observed for the VAS FA and SF-12. For both time points, neither fracture type nor characteristics significantly influenced any outcome parameter assessed. Conclusion: Functional treatment by full weightbearing and free range of motion led to excellent 5-year results for both type I and II fractures. Neither fracture location nor characteristics had a significant influence on the 5-year PROMs

Weightbearing Radiography and MRI Findings in Ankle Fractures.

Background. Static weightbearing radiography can be used to assess stability in ankle fractures by measuring lateral talar shift (medial clear space; MCS). However, the correlation of a stable ankle joint under weightbearing load and the structural integrity of the deltoid ligament has not been shown. In this study, we assessed deltoid ligament integrity on magnetic resonance imaging (MRI) and correlated that with weightbearing and gravity stress test radiography. Methods. Thirty-four patients with supination external rotation II-IV (SER) fractures underwent MRI, weightbearing radiography, and gravity stress test. On MRI, the deep anterior and posterior tibiotalar deltoid, tibionavicular and tibiocalcaneal ligaments, as well as the syndesmosis were assessed as intact, partial rupture, or complete rupture. The MCS was measured as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise view. Results. Twenty-three patients suffered a deep anterior tibiotalar ligament rupture (16 partial; 7 complete) and 2 a deep posterior tibiotalar ligament tear (1 partial; 1 complete). For MCS on weightbearing radiography, no statistically significant differences were identified between any of the individual groups. With gravity stress radiography, only a complete tear of the tibiocalcaneal ligament showed a significantly higher MCS than a partial tear or intact tibiocalcaneal ligament (P < .005). No other ligament disruption showed a significant difference between the complete rupture versus intact or partial tear. Conclusion. Weightbearing radiography does not show much variation in terms of MCS even with ligamentous disruption and fibula fracture. The talus often centers itself underneath the tibia with weightbearing radiography. Levels of Evidence: Level III: Retrospective cohort study