Welcome to our fifth episode of the Ankle Surgery Update. We are a little bit delayed and we hope you do excuse :) We decided to split this month's episode in two parts. In this first part, we will be presenting and discussion the following 2 papers published recently:
Thank you very much for listening to Ankle Surgery Update – Science Guiding Treatment. We hope you enjoyed this episode and make sure to tune in in 3 weeks, when the second part will go online!
Hans & Sebastian
Welcome to our fifth episode of the Ankle Surgery Update. We are a little bit delayed and we hope you do excuse :) We decided to split this month's episode in two parts. In this first part, we will be presenting and discussion the following 2 papers published recently:
Thank you very much for listening to Ankle Surgery Update – Science Guiding Treatment. We hope you enjoyed this episode and make sure to tune in in 3 weeks, when the second part will go online!
Hans & Sebastian
Hi, everybody. Welcome to our fifth episode of ankle surgery update science guiding treatment. We are deeply sorry for the delay of this month's episode. Following a period of covered restrictions, we had to focus on catching up on patient care and research projects. Germany still has certain social distancing restrictions in place, which we are deeply happy for. With the holiday time coming up, we hope that the public will continue to act responsibly. But let's have a look at what has been published recently. We decided to split this episode in two parts, which will be published at an interval of three weeks. For the first part, we will have a look at the study by Matheny Rao who had a closer look at the commonly use patient reported outcome measures in the foot and ankle. Further we will discuss a paper on by lateral simultaneous hallux MTP fusion, published by metars. Our
Unknown Speaker :first study of this episode is entitled patient reported outcome measures and foot and ankle. normative values do not reflect 100% full function by metheny at all published in Casta, the way we read outcome following foot and ankle surgery has changed considerably over the last 30 years. Back in the days binary patient satisfaction and or objective measurements, like range of motion or radiographic alignment were the predominant outcome parameters chosen. Still we have realised that outcome is something highly subjective and patient specific. Therefore, various disease specific patient reported outcome measures were developed these to not only allow to assess the outcome of a treatment by comparing baseline to follow up measures, but also to give our patients a perspective on the subjective treatment outcome prior to intervention. methods and colleagues evaluated commonly used outcome measures and foot and ankle surgery, the foot and ankle ability measure farm which scores in an activity of daily living ADL domain, and the sports domain, the foot and ankle visibility index, Fadi the taegan activity scale, and the SF 12 quality of life score, which composes of a physical component PCs and the mental component MCs score. The primary aim of the study was to determine normative values for these scores in the normal population. A confirmatory factor analysis model was used to assess the latent variable anchor function based on the farm idea farm sport as of 12, PCs, and body pain questionnaires. On average, 63% of patients were female, the mean age was 31 plus minus 15 years and the BMI 26 plus minus 629 people equalling 11% had previous ankle surgery, sex, h BMI and previous ankle surgery status at a significant influence and all prom outcome scores. Although significant, all scores but the SF 12 MCs showed only moderate to weak correlations between each other reliability of each score was good to excellent. The authors then conducted a confirmatory factor analysis to assess the latent variable ankle functional ability as a function of the farm IBL farms board and sF 12 PCs and the fardy power so the model demonstrated an excellent fit without any modifications. The others concluded that normative values of foot and ankle outcome measures did not reflect 100% function and different by sex, age, BMI and previous ankle surgery status. But the confirmatory factor analysis model demonstrated excellent fit, and highlights the aggregated use of different outcome measures to reflect ankle function. Hands. In the course of our study ambitions. We had long discussions on outcome assessment, and statistics and foot and ankle research. Based on this paper, we apparently are not the only ones to reflect on the current use of outcome measures. Statistics to us remain, or even are the essential part of any paper. But although I'm pretty interested in statistics and orthopaedic surgeon level,
Unknown Speaker :I had a hard time to follow the statistics applied in this paper. Actually, I had to do some background reading in order to understand what the confirmatory factor analysis actually is, without a general understanding of the statistics applied, in this case, confirmatory factor analysis, one cannot comprehend what the authors were trying to show. So maybe we asking for what we in Germany called the egg Lang will milk so something that would be awesome to have butter doesn't really exist? Or do you think that we will have at some point mechanism by hands that allow a comprehensive methodology that is still comprehensible for Orthopaedic Surgeons?
Unknown Speaker :Thanks, Sebastian for this excellent summary, and I exactly feel what you mean. Let's first have a brief look at the study in general. In the first part of the study, the author's aimed at assessing normative values for for commonly used patient rated outcome measures. They aim to include a representative nominal cohort
Unknown Speaker :using a convenient sampling method. This methodology
Unknown Speaker :was not further specified, and the only inclusion and exclusion criteria stated were age above 18 years. But as the court analysed did include persons with previous ankle surgery, it appears reasonable that it also did include patients with compromised ankle functionality. I'm not sure whether the patient cord used to define or analyse normative values should include patients with compromised and called function. This limitation is not further elaborated by the author's assuming the patient court with no subjective impairment of foot and ankle function, one would still assume that the mean score of the problems would not be 100,
Unknown Speaker :as any score should try to avoid a ceiling effect. This means that only the fittest can score 100% and the general population, although they might not have a subjective impairment, would not reach the total score. avoiding a ceiling effect helps to discriminate good from very good patient rated outcomes
Unknown Speaker :for the current study,
Unknown Speaker :the FA m ADL scores, and those patients with previous ankle surgery was 93 plus minus 12 points. One could assume that a cohort of people without any subjective impairment would show a narrower standard deviation. Furthermore, h sex and BMI Each had a significant influence on the outcome scores. Maybe at some point of time, we will have scores available that included weighting factors to account for these natural differences. This will increase the comparability between studies considerably. Second, you raise the question about the outcome assessment in foot and ankle research in general. When looking at problems available for foot and ankle, one can find a vast variety of general and specific scores with varying validity and reliability. Still, these problems are used more or less randomly by different research groups for different pathologies. Moreover, not only the outcome measures used, but also the time when they are assessed various considerably. We've talked about this before in our podcast, but we cannot emphasise enough that we as a research community have to team up and strictly define on how and when outcome measures are assessed for each pathology separately. Finally, statistics, I think we all do have a general understanding of basic parametric and nonparametric statistics. But we have also learned that this unit dimensional, only looking at the effect of single parameters on the outcome is insufficient is shown in the current study. Multiple parameters such as age, sex, and BMI, have an effect on the patient rating outcome, but applying sufficient statistic, such as multi regression analysis, propensity score matching, or is done in this paper, confirmatory factor analysis does exceed the level of statistics Orthopaedic Surgeons can conduct by themselves. Therefore, as academic surgeons necessitate an interdisciplinary network to conduct meaningful and valid research, still, research settings vary considerably throughout the world. For us in Germany, for example, there's little infrastructure provided we design and conduct research by ourselves, some stays true for the analysis. In case we want to perform analysis that we are not comfortable with, such as multivariate regression analysis, propensity score matching metaanalysis, or confirmatory factor analysis, it is on us to find a statistician to help us with the analysis. Contrary, in the United States, for example, universities maintain an infrastructure, including information lists and statisticians, which are involved in every step of the study design, implementation, and analysis. This type of infrastructure does not only allow the surgeon to effectively implement research in their clinical routine, but it also does increase the meaningfulness and the impact of the research conducted significantly.
Unknown Speaker :So what did we learn for the practice? We ended up not talking too much about the actual study presented. Still, this to me has been a meaningful discussion. I think there are two main take home messages. First. Even though prompts are a great achievement over the traditional methods of outcome assessment. The individual prompts are not robust and do not reflect all aspects of ankle functionality. Second, research is a team effort. Research must be conducted in an interdisciplinary team to not only apply the right methodology, but also to draw the right conclusions based on the most precise statistics available with respect to prompt. We, for example, could team up with such decisions and psychologists who have a long standing history of subjective outcome assessment to actually develop valid prompts that reflect all aspects of ankle functionality.
Unknown Speaker :The second paper discussed in this month's episode was published in foot and ankle surgery by metadata. The studies entitled outcomes of bilateral simultaneous halex MTP joint fusion. After these is off the first MTP joint is frequently performed is hellos. rigidus is a common situation. The chorus for this disease is still unknown. There is definitely an accumulation in families and many patients suffer from bilateral pathology. Therefore genetic factors must be involved. As a consequence, many patients require bilateral athlete eases. The vast majority of foot and ankle surgeons has concerns to perform a thesis simultaneously on both feet. The concern is that the patient will be severely incapacitated in the early post operative period. Furthermore, the inability to partially bear weight might lead to an increase in non union. In this retrospective study, 16 patients who underwent bilateral simultaneous first MTP joint after dieses were compared to 16 patients with unilateral MTP aphrodisiacs with regards to outcome tolerance, cost and time effectiveness. All procedures were carried out using dorsal locking plates. outcome measures were evaluated using the American orthopaedic foot Medical Society score and the self reported foot and ankle questionnaire. For the bilateral group only. The eo FA s was collected for the bilateral group only and compared to the results reported in literature for unilateral fusions. Regarding the scfas grading 88% had good or excellent outcome scores in both groups. The post op a or FA s was 86 in the bilateral group, and comparable to unilateral surgeries reported in the literature. The average duration of surgery in the bilateral group was 118 minutes compared to 70 minutes in the unilateral group. This time was calculated without the time needed for anaesthesia, which would be significantly higher in the unilateral group. This translated to an average hospital cost of 5325 euro for the bilateral and 4295 euro for the unilateral procedure. The average time off work was 7.3 weeks for the bilateral group. For the unilateral group, the average time of work was 5.7 weeks for both feet. This would add up to 11.4 weeks to patients suffering from rheumatoid arthritis in the bilateral group developed bilateral non unions, with one tool being symptomatic. One patient operated unilateral also suffered a symptomatic and non union wound healing problems were observed in one patient in the bilateral groups which were treated non operatively. The authors concluded that bilateral simultaneous hallux MTP joined a thesis is in effect convenient and cost effective option for patients requiring MTP fusions for bilateral hallux pathology.
Unknown Speaker :That really is an interesting study, as we also have been concerned performing this procedure bilaterally. Nevertheless, some aspects should be discussed. Most of the limitations are typical for retrospective studies. First, the number is very limited with 16 patients per group only. Second, the study was not randomised. The eo FA s was not collected for the unilateral group. As a consequence, the results were comparable to the literature. No sample size calculation was conducted, given that this study was based on available data. Furthermore, during the course of the study, the implant was changed.
Unknown Speaker :Yes, Sebastian, I fully agree. But besides these limitations, for me, it really reduced my concerns to perform a thesis of the First MTP joint bilaterally. Nevertheless, I believe that these patients still should be selected carefully. At least in the beginning, I would rather offer this to younger and more active patients. And probably, I would not select high risk patients, for example suffering from rheumatoid arthritis.
Unknown Speaker :As always, you can find links to the cited papers in the description of this episode. Thank you very much for listening to anchor surgery update science guiding treatment. Make sure to tune in for the second part of this month episode in three weeks time.