Large-scale clinical implementation of PROMIS computer adaptive testing with direct incorporation into the electronic medical record.

The objective of this research was to assess the implementation of collecting patient-reported outcomes data in the outpatient clinics of a large academic hospital and identify potential barriers and solutions to such an implementation. Three PROMIS computer adaptive test instruments, (1) physical function, (2) pain interference, and (3) depression, were administered at 23,813 patient encounters using a novel software platform on tablet computers. The average time to complete was 3.50 ± 3.12 min, with a median time of 2.60 min. Registration times for new patients did not change significantly, 6.87 ± 3.34 to 7.19 ± 2.69 min. Registration times increased for follow-up (p = .007) from 2.94 ± 1.57 (p < .01) min to 3.32 ± 1.78 min. This is an effective implementation strategy to collect patient-reported outcomes and directly import the results into the electronic medical record in real time for use during the clinical visit.

Is barefoot regional plantar loading related to self-reported foot pain in patients with midfoot osteoarthritis.

OBJECTIVE: While recent evidence suggests that foot pain may be related to mechanical stress, quantitative data elucidating the role of regional plantar loading in foot pain in individuals with midfoot osteoarthritis (OA) are lacking. Therefore the authors' objective is to examine regional plantar loading and self-reported foot pain in patients with midfoot OA compared to asymptomatic, matched control subjects. METHOD: Fifty subjects, 30 patients with midfoot OA and 20 control subjects participated in this study. Self-reported function was assessed using the Foot Function Index-Revised (FFI-R). Plantar loading during barefoot walking at self-selected, monitored walking speed was quantified using an EMED pedobarograph. Between-group differences in FFI-R score and plantar loading were assessed using an independent t-test and the Mann-Whitney U-test respectively. The relationship between FFI-R score and plantar loading was assessed using Spearman rank correlation. A k-means cluster analysis was used to identify potential sub-groups of patients through regional plantar loading. RESULTS: The key findings of this study showed that patients with midfoot OA reported significantly higher FFI-R scores, and higher heel and medial midfoot average pressure compared to control subjects. Medial midfoot pressure-time integral was positively associated with FFI-R Pain Subscale Score (r=0.524, P<0.01). Based on the adequacy index, the two-cluster solution was deemed most appropriate. CONCLUSION: This study demonstrated that patients with midfoot OA sustain increased magnitude and duration of regional plantar loading during walking compared to matched control subjects. Our findings support the theory that regional mechanical stress may be associated with symptoms in patients with midfoot OA. Future studies should assess whether interventions designed to reduce plantar loading are effective in relieving foot pain, and preventing progression of symptoms in patients with midfoot OA.

Osteotomies of the fifth metatarsal.

Although the literature is limited primarily to retrospective small case series of the operative technique of fifth metatarsal osteotomies with a short follow-up, some important information can be learned. Stabilization of the osteotomy with Kirschner wire fixation appears to decrease dorsal displacement of the distal fragment and distal osteotomies; this leads to decreased incidence of transfer metatarsalgia. Kirschner wire fixation is advocated. The proximal chevron osteotomy of the fifth metatarsal, although stable, has a 20% delayed union rate, most likely resulting from the unique vascular anatomy in this region. The radiographic and clinical results appear to be compatible between distal and proximal osteotomies. Based on this information, primary use of a proximal osteotomy technique is not recommended. The oblique diaphyseal osteotomy technique requires an incision for the osteotomy as well as a distal incision at the metatarsophalangeal joint for correction of this joint. Hardware removal was performed in most patients, and the complications included two cases of delayed union. Time to healing was reported to be 8 weeks, 1.5 times the reported time to healing in distal chevron osteotomies. A significant radiographic correction was noted with the oblique diaphyseal osteotomy; however, radiographic measurements can be altered with foot position and lack of x-ray standardization and technique. Kitaoka et al found no correlation with the degree of radiographic correction and post-operative clinical symptoms. The authors agree with Kitaoka et al that the oblique diaphyseal osteotomy should be reserved for patients who fail an initial distal osteotomy technique. Distal oblique osteotomies appear to have less stability and more complications with malunion, transfer metatarsalgia, and delayed union and should be abandoned for a more stable chevron technique. The distal chevron osteotomy has a small incidence of transfer metatarsalgia; however, it appears to improve the clinical radiographic appearance of [table: see text] the foot with a shortened time to healing (4 to 6 weeks). A biplanar technique can be employed with a distal chevron osteotomy to improve plantar callosity symptoms. More studies are needed to examine critically patient outcomes with uniplanar and biplanar techniques using the distal chevron osteotomy.

Ankle ligament injury risk factors: a prospective study of college athletes.

Over two million individuals suffer ankle ligament trauma each year in the United States, more than half of these injuries are severe ligament sprains; however, very little is known about the factors that predispose individuals to these injuries. The purpose of this study was to determine the risk factors associated with ankle injury. We performed a prospective study of 118 Division I collegiate athletes who participated in soccer, lacrosse, or field hockey. Prior to the start of the athletic season, potential ankle injury risk factors were measured, subjects were monitored during the athletic season, and injuries documented. The number of ankle injuries per 1,000 person-days of exposure to sports was 1.6 for the men and 2.2 for the women. There were 13 injuries among the 68 women (19%) and seven injuries among the 50 men (13%), but these proportions were not significantly different. Women who played soccer had a higher incidence of ankle injury than those who played field hockey or lacrosse. Among men, there was no relationship between type of sport and incidence of injury. Factors associated with ankle ligament injury differ for men relative to women. Women with increased tibial varum and calcaneal eversion range of motion are at greater risk of suffering ankle ligament trauma, while men with increased talar tilt are at greater risk. Generalized joint laxity, strength, postural stability, and muscle reaction time were unrelated to injury.

Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait.

BACKGROUND: The range of joint motion is a commonly reported outcome measure in assessment of the great toe. Although motion of the first metatarsophalangeal joint during gait is of primary functional importance, clinicians rely on relatively static clinical measures to assess this joint. The relationship between the results of commonly used clinical tests of motion of the first metatarsophalangeal joint and motion of this joint during gait was assessed in a study of thirty-three subjects who had no history of a pathological condition of the foot or ankle. METHODS: An electromagnetic tracking device was used to acquire three-dimensional orientation data on the hallux with respect to the first metatarsal. Receivers were secured to the skin overlying the proximal phalanx of the hallux, the first metatarsal, and the medial aspect of the calcaneus. Measurements were recorded during four clinical tests. These tests assessed the active range of motion of the first metatarsophalangeal joint with the subject weight-bearing, the passive range of motion with the subject weight-bearing, the passive range of motion with the subject non-weight-bearing, and the motion during a heel-rise. The data collected with these tests were compared with motion of the first metatarsophalangeal joint during walking. The focus of the analysis was the dorsiflexion component of rotation. RESULTS: With the exception of the passive range of motion with the subject weight-bearing, the ranges of motion measured during all of the clinical tests exceeded the motion of the first metatarsal joint that is required during normal walking. The motion measured during heel-rise (r = 0.87, p < 0.001) and the active range of motion with the subject weight-bearing (r = 0.80, p < 0.001) had the strongest correlations with motion of the first metatarsophalangeal joint during gait. The mean dorsiflexion during the test of the active range of motion (44 degrees) was closer to the mean dorsiflexion during gait (42 degrees) than was the mean value measured during the heel-rise test (58 degrees). This study also demonstrated that the clinical tests are not interchangeable as their mean results differed by as much as 21 degrees. CONCLUSIONS: The selection of a reliable and valid clinical test and an understanding of the relationship of the results of this test to the motion requirements during normal gait will help to standardize reporting techniques and will improve the ability of the clinician to determine the outcomes of treatment. This study showed that measurement of the active range of motion with the subject weight-bearing was a reliable and valid test and that the results were strongly correlated with motion of the first metatarsophalangeal joint during gait.

Reliability and validity of first metatarsophalangeal joint orientation measured with an electromagnetic tracking device.

OBJECTIVE: To establish the reliability and validity of measurements of sagittal plane orientation of the first metatarsophalangeal joint using the Flock of Birds electromagnetic tracking device. DESIGN: Different joint orientations were reproduced on cadaver specimens in a specially designed jig with skin and skeletal application of the sensors. BACKGROUND: The Flock of Birds provides a means for quantifying first metatarsophalangeal joint motion, however, the reliability and validity of such an application has not been determined. METHODS: Joint orientation was measured in five cadaver feet with skin and skeletal sensor application. A specially designed jig allowed simulation of clinical tests of range of motion. Sagittal plane orientation was determined from 3-D, anatomically-based, reference frames embedded in the first metatarsal and proximal hallux. RESULTS: Reliability of all measurements was high for skin and skeletal sensor application. There were no significant differences in joint orientation between either technique for any of the simulated motion tests. CONCLUSIONS: The Flock of Birds provides reliable and valid measures of first metatarsophalangeal joint orientation with the sensors applied to the skin over the first metatarsal and proximal hallux. RELEVANCE: An electromagnetic tracking device is suitable for measuring sagittal plane motion of the first metatarsophalangeal joint. This motion can easily be expressed using 3-D, anatomically-based reference frames.

Total calcanectomy for the treatment of chronic calcaneal osteomyelitis.

The purpose of this study is to present the surgical and functional results of a total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus. A retrospective review identified eight patients treated with a total calcanectomy for a chronic nonhealing plantar ulcer of the heel and osteomyelitis of the calcaneus. The primary diagnosis was insulin-dependent diabetes mellitus (six patients), pneumococcal septicemia (one patient), and an open calcaneal fracture (one patient). The average age of the patients was 52 years. Prior procedures included irrigation and debridement of the heel ulcer (seven patients), partial calcanectomy (three patients), and split thickness skin grafting (two patients). The vascular status of each limb was assessed preoperatively. Distal extremity bypass surgery was performed on two patients before calcanectomy. Osteomyelitis of the calcaneus was diagnosed by magnetic resonance imaging alone in three patients, and by technetium/indium scans and magnetic resonance imaging in five patients. The average follow-up duration was 27.3 months (range, 6-57 months). Infection at the plantar heel was controlled in all patients. In all eight cases the incisions were closed primarily. During a prolonged time of total contact casting to facilitate wound healing, one patient developed an anterior tibial ulcer that progressed to osteomyelitis and underwent below-knee amputation. Talonavicular subluxation occurred as a late complication in one patient. This was treated with a talonavicular arthrodesis and subsequent bracing for a nonunion. An assessment of functional ambulation was performed on all eight patients. Four patients maintained the same ambulation level postoperatively in a modified heel-containment orthosis. Two patients decreased one functional ambulation level, and one patient decreased two levels. One patient underwent below-knee amputation and is currently ambulatory with a prothesis. Assessment of ankle strength and range of motion of the surgical limb demonstrated decreased dorsiflexion and plantarflexion strength and a variable range of motion compared to the contralateral limb. Total calcanectomy is an alternative procedure to transtibial amputation in patients with chronic osteomyelitis of the calcaneus. Eradication of infection and preservation of the functional ambulation is achieved.

A comparison study of plantar foot pressure in a standardized shoe, total contact cast, and prefabricated pneumatic walking brace.

Total contact casting is the current recommended treatment for Wagner Stage 1 and 2 neuropathic plantar ulcers. The rationale for this treatment includes the equalization of plantar foot pressures and generalized unweighting of the foot through a total contact fit at the calf. Total contact casting requires meticulous technique and multiple cast applications to avoid complications before ulcer healing. An alternative to total contact casting is the use of a prefabricated brace designed to maintain a total contact fit. This study compares plantar foot pressure metrics in a standardized shoe (SS), total contact cast (TCC), and prefabricated pneumatic walking brace (PPWB). Five plantar foot sensors (Interlink Electronics, Santa Barbara, CA) were placed at the first, third, and fifth metatarsal heads, fifth metatarsal base, and midplantar heel of 10 healthy male subjects. Each subject walked at a constant speed over a distance of 280 meters in a SS, PPWB, and TCC. A custom-made portable microprocessor-based system, with demonstrated accuracy and reliability, was used to acquire the data. No significant differences in peak pressure or contact duration were found between the initial and repeat SS trials (P > 0.05). Peak pressures were reduced in the PPWB as compared to the SS for all sensor locations (P < 0.05). Similarly, peak pressures were reduced in the TCC compared to the SS for all sensor locations (P < 0.05) with the exception of the fifth metatarsal base (P = 0.45). Our results are summarized as follows: (1) the methods used in the current study were found to be reliable through a test-retest analysis; (2) the PPWB decreased peak plantar foot pressures to an equal or greater degree than the TCC in all tested locations of the forefoot, midfoot, and hindfoot; (3) compared to a SS, contact durations were increased in both the TCC and PPWB for most sensor locations; and (4) the relationship of peak pressure over time, the pressure-time integral, is lower in the brace compared to the shoe at the majority of sensor locations. The values are not significantly different between the cast and shoe. These findings suggest an unweighting of the plantar foot and equalization of plantar foot pressures with both the PPWB and TCC. Based on these findings, the PPWB may be useful in the treatment of neuropathic plantar ulcerations of the foot.

Test-retest reliability of ankle injury risk factors.

Ligamentous instability, ankle muscle weakness, foot-ankle alignment, and generalized joint laxity may be predisposing factors for ankle ligament injuries. The purpose of this study was to examine the reliability of these risk factors before and after the season in healthy individuals and to determine if any significant differences developed during the athletic season (range, 12 to 16 weeks). Twenty-one healthy college-aged athletes were tested for generalized joint laxity, anatomic alignment of the foot and ankle, ligamentous stability, and isokinetic strength of the ankle muscles. This study showed that generalized joint laxity, ankle ligamentous stability, and ankle strength measurements demonstrated high correlation coefficients (r > 0.75). The high correlation coefficients suggested reliable measures. Some of the range of motion measurements had lower correlation coefficients, which suggested more variability in these measurements. After establishing the reliability in 24 of the 28 measurements with standardized methods, further work is underway to evaluate the role of these factors in inversion ankle sprains.

A prospective study of ankle injury risk factors.

Many factors are thought to cause ankle ligament injuries. The purpose of this study was to examine injury risk factors prospectively and determine if an abnormality in any one or a combination of factors identifies an individual, or an ankle, at risk for subsequent inversion ankle injury. We examined 145 college-aged athletes before the athletic season and measured generalized joint laxity, anatomic foot and ankle alignment, ankle ligament stability, and isokinetic strength. These athletes were monitored throughout the season. Fifteen athletes incurred inversion ankle injuries. Statistical analyses were performed using both within-group (uninjured versus injured groups) data and within-subject (injured versus uninjured ankles) data. No significant differences were found between the injured (N = 15) and uninjured (N = 130) groups in any of the parameters measured. However, the eversion-to-inversion strength ratio was significantly greater for the injured group compared with the uninjured group. Analysis of the within-subject data demonstrated that plantar flexion strength and the ratio of dorsiflexion to plantar flexion strength was significantly different for the injured ankle compared with the contralateral uninjured ankle. Individuals with a muscle strength imbalance as measured by an elevated eversion-to-inversion ratio exhibited a higher incidence of inversion ankle sprains. Ankles with greater plantar flexion strength and a smaller dorsiflexion-to-plantar flexion ratio also had a higher incidence of inversion ankle sprains.

Controversies in treating talus fractures.

Controversies of talus fractures are related to the rare incidence of these fractures and the even more sparse, clinically based, objective research examining treatment outcomes. This article outlines various talus fracture types, treatment, and treatment controversies. A discussion section summarizing treatment controversies of talar neck fractures, the most common talus fracture, is also included.

Tendon injuries of the foot and ankle.

Tendon injuries are often caused by direct trauma or overuse. Pathology may consist of inflammatory lesions external to the tendon sheath or inflammation of either the peritenon, sheath, or tendon. This article reviews the diagnosis and treatment of injuries to the peroneal, peroneus brevis, peroneus longus, anterior tibial, flexor hallucis longus, and posterior tibial tendons.