“Because of the way the bunion correction is performed with MISB, there is a thought that it may not help stabilize the foot in the same way that the more extensive, open procedures performed at the midfoot do,” said study senior author Anne Holland Johnson, MD, a foot and ankle surgeon at HSS. “When someone has a flatfoot deformity, which is essentially a fallen arch, the idea is that fixing the bunion through this minimally invasive technique could make the flatfoot worse because we cut the bones closer to the toe. What we found is that it was quite the opposite—that fixing the bunion in a minimally invasive way caused no changes in the overall flatfoot dimensions.”

“Bunion” is an umbrella term describing a variety of painful deformities at the base of the big toe. In the most common type of bunion, called hallux valgus, the big toe turns inward from its normal position and angles toward the second toe. Hallux valgus often presents with secondary structural deformities such as flatfoot, which can be symptomatic or asymptomatic (causing no symptoms).

All techniques for treating bunions involve cutting the bones and repositioning them with metal screws. The minimally invasive chevron and akin bunionectomy (MISB) fixes the bunion by cutting the bones through tiny incisions in the skin. “The advantages of doing the surgery through small incisions include minimal to no pain after the surgery; immediate weight bearing, so you can walk normally on the foot; and faster return to day-to-day activities and sports,” said Dr. Johnson.

The researchers conducted a retrospective study using a patient registry at HSS. In the registry, they identified patients who were over 18 years of age and were diagnosed with a bunion deformity between 2016 and 2021. Of this cohort, patients were included in the study if they underwent a MISB procedure to correct a hallux valgus deformity; reported their outcomes for at least one year and up to two years, as recorded by a patient-reported outcomes tool known as PROMIS; and had x-rays before and three months after surgery, at minimum. Using preoperative x-rays, the team identified individuals who had evidence of flatfoot; using a chart review, they also identified those with an asymptomatic flatfoot. These reviews yielded a study group of 35 patients with asymptomatic flatfoot and 47 patients without flatfoot.

“We collected PROMIS surveys on all our patients. These are a series of questionnaires that have been validated for use in foot and ankle research and ask the patient about their function, pain, and mental health,” said Rami Mizher, lead author of the study and a research assistant in the Department of Foot and Ankle Surgery at HSS. The researchers found that MISB resulted in similar improvements in the two groups in physical function, pain interference (how often the pain interferes with daily life), pain intensity, and global physical health (overall patient health), as measured by the PROMIS survey. There were no significant preoperative to postoperative changes in PROMIS global mental health and depression measures in either group.

A chart review showed there was no difference in complications in the two study groups.

The researchers also examined pre- and post-operative x-rays to clinically assess how well the surgery corrected the bunion deformity and if it changed any of the flatfoot-related measurements. In both groups, there was a similar correction of the bunion deformity. In terms of the flatfoot outcomes, the researchers looked at three different parameters: calcaneal pitch, or the height of the foot arch; Meary’s angle, which measures how much a foot sags; and talonavicular coverage angle, which measures how much the foot turns outward. The first two measures didn’t have any significant changes, while the talonavicular coverage angle improved in the flatfoot group.

“Our research shows that you can fix the bunion with this comparatively easier procedure and not make the flatfoot worse,” said Dr. Johnson. “It proves that minimally invasive bunion correction is a viable option for patients with flatfoot.”

 Authors: Rami Mizher, BS; Lavan Rajan, BA; Jaeyoung Kim, MD; Syian Srikumar, BS; Elizabeth Cody, MD; Anne Holland Johnson, MD; Scott Ellis, MD (HSS)

A new study by researchers at Hospital for Special Surgery (HSS) in New York City provides attainable goals for return to sports and related physical activities for patients who have undergone procedures to correct progressive collapsing foot deformity (PCFD), a severe musculoskeletal pathology that can drastically inhibit a patient’s daily function. The findings were presented today at the American Academy of Orthopaedic Surgeons (AAOS) 2022 Annual Meeting.

“This procedure is the epitome of big surgery,” said Scott J. Ellis, MD, an orthopaedic foot and ankle surgeon at HSS and the senior researcher on the study. “It is associated with a long recovery period, and patients are quite immobile even before they reach the operating room. As a result, even surgeons want to know: Is this going to be worth it?”

Dr. Ellis added, “PCFD is a debilitating condition marked by several progressive deformities that require a combination of extensive reconstructive procedures, from cutting and reshaping bones in the foot to rerouting tendons in the fallen arch. Although patients can expect to eventually resume at least light to moderate physical activity, the recovery period can take many months to a year or more, and some of the most vigorous sports may not be possible.”

This study is the first attempt to quantify the recovery period for individual activities. The HSS research team, led by clinical research scientist Robert Fuller, analyzed patient-reported data from 82 patients, aged 18 to 60 years, who had undergone reconstructive foot surgery at the hospital between February 2016 and May 2019. About three-fourths of the patients were women, and the average time since surgery was approximately 3 years (range, 2 to 5.4 years).

Patients were asked about their ability to return to 21 physical activities, such as yoga, biking, walking and running, as well as their overall level of function, pain and other outcomes using the HSS Orthopaedic Foot and Ankle Registry, a rich repository of data that helps clinicians and researchers better guide treatment decisions.  

According to the findings, patients said that half of the 21 activities had become easier for them to perform after surgery, while 33% experienced no difference and 17% said the activities had become more challenging. Improvements in physical function (P=0021), pain (P=0.001) and global physical health (P=0.001) were associated with statistically significant increases in patient satisfaction with respect to sports and physical activities.

No patients surveyed said they had stopped doing activities they had performed before surgery, but many said they had taken up new activities—mainly low-impact pursuits such as walking, biking and swimming. Overall, 74 of the 82 patients (90%) reported being somewhat to very satisfied with their ability to be active, while just eight (10%) said they were unsatisfied with the results of the surgery in that regard.

The most exciting part of the study, Fuller said, was that the researchers were able to collect enough data on individual physical activities that they can now advise patients not only on the types of activities they can expect to carry out, but also on the length of time they can expect to be off their feet after surgery.

“We think this study gives us the ability to say to a patient, ‘If you're interested in doing yoga again, you can expect to return in about six to nine months and be back to full form in about a year,’” Fuller said. “It can help provide clarity for a lot of people showing these surgeries can be life-changing in terms of getting them active again, but a substantial amount of people will face some extended recovery.” Indeed, the researchers found that 22% of patients said they never reached their maximum preoperative level of participation in physical activities, and 26% said the difficulties they experienced in performing activities had increased after surgery.

Not surprisingly, Fuller said, people who undergo foot reconstruction can resume low-impact activities—faster than those who practice more demanding sports such as dancing, jogging, skiing or basketball. However, “we observed great progress in both high- and low-impact activities,” he added.

Although the new research highlights the effectiveness of the reconstructive procedure, Fuller and Dr. Ellis said more work is needed to help standardize good outcomes for patients. At HSS, Dr. Ellis and his colleagues are using new technologies such as weight-bearing CT scanning to help identify which bones in the affected foot are collapsing and which ligaments are failing to better understand the anatomy of the deformities and optimize the surgical plan. They also are incorporating a computer modeling technique called finite element analysis to simulate how the foot will appear after the bones and other tissues are cut.

 “We plan to use the data from this study to provide patients with realistic expectations and timelines regarding their return to sports activities after collapsing flatfoot reconstruction, and as a resource for patients at the time when surgery is being discussed,” Dr. Ellis concluded.

The findings, published in the journal Foot and Ankle International and presented today at the American Academy of Orthopaedic Surgeons (AAOS) 2021 annual meeting, found that patients with the most severe impairment, both physical and, to a somewhat lesser degree, emotional, before reconstructive surgery reported the most gains after the procedure.

Adult-acquired flatfoot deformity, more recently known as progressive collapsing foot deformity (PCFD) or “fallen arches,” is relatively common with age. The condition, which affects at least 3% of women over age 40 and more than 10% of people over age 65, results from weakening, stretching or other alterations to the tendons and ligaments in the foot and can lead to severe pain and significantly restricted mobility. Women are more prone to the problem than men; and being overweight is considered an increased risk factor.

A mix of stretching, physical therapy and the use of orthotic devices may help people with milder cases. But for the more severe cases of PCFD, surgeons can operate to reshape and restore function to the affected extremity.

“Once the foot starts collapsing, it never uncollapses, and the worry is that over time the ligaments will continue to stretch, the foot will flatten, and the pain will increase,” said Scott J. Ellis, MD, a foot and ankle surgeon at HSS and senior author of the study. Although nonsurgical or conservative management appears to help prevent the progression of PCFD, Dr. Ellis noted that hasn’t been conclusively proven. “Roughly half of patients will need surgery. If the foot continues to hurt and limits quality of life and function, and there’s pain from walking, travel and other activities, then we say it’s time to perform surgery.”

Determining which patients stand to benefit most from foot reconstruction — and who would do better with more conservative management — has been unclear.

For the new study, Dr. Ellis and his colleagues sought to determine if instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) could help physicians predict which patients would experience the most improvement from foot surgery. PROMIS has multiple components, including scores for physical function, pain scale and depression, and is considered an objective measure of a patient’s physical and mental health specific to a given condition.

The HSS team, including Matt Conti, MD, a chief resident and the first author on the paper, identified 71 men and women (75 feet in total) who underwent surgery for PCFD between February 2016 and April 2018, and for whom PROMIS data were also available. The average follow-up time for the patients was roughly 27 months.

Patients with the lowest PROMIS scores for physical function (PROMIS-PF) before surgery — indicating the most severe impairment — were most likely to experience clinically meaningful improvements two years after the procedure, according to the researchers. Those with a PROMIS-PF score of 45.7 had roughly a 14% chance of improvement, while patients with a score below 40.9 had nearly a 98% chance of clinical gains.

Armed with the new information, surgeons now have a more objective way of informing patients of their chances of a successful operation. “When a patient walks in the door, you can get an idea of where they stand on that scale, and we know based on our study where patients need to land to achieve clinically meaningful improvements from the surgery,” Dr. Ellis said. “It could be a real-time decision with the patient and something they could follow over time to allow them to see the trajectory of their recovery and where they are heading.”

Every patient scheduled for surgery at HSS completes the PROMIS survey, and the results become part of the electronic medical record. As a result, HSS has built one of the nation’s most robust and detailed databases of patient-reported outcomes, enabling its physicians and researchers to optimize the care they provide. “A similar study could be conducted across a whole different host of conditions,” Dr. Ellis concluded.