Patient reported outcomes six months following surgical treatment of end stage hallux rigidus in a community based podiatric surgery service
Introduction
Hallux rigidus is a common painful complaint which may have a deleterious impact on a patient’s health related quality of life (HRQOL) [1]. As the disease progresses to its more severe form patients who remain symptomatic may request surgical intervention. Painful end stage or severe hallux rigidus has been treated surgically for over 100 years and much has been published about the results of surgical intervention [2]. Many procedures have been described for the management of hallux rigidus such as cheilectomy, osteotomy and joint resurfacing. The options for severe disease can be grouped into three categories; arthrodesis, excisional arthroplasty and joint replacement by means of an implant arthroplasty [3]. To date evaluation of these techniques has largely focused on clinical indicators such as radiographic findings, complications and subjective examination of joint range of motion or other clinical features [4].
Relatively little attention has been given to HRQOL following hallux rigidus surgery and indeed the use of patient reported outcome measures is still not a routine feature of published foot and ankle surgery research [5]. This study utilised PASCOM-10 (www.pascom-10.com) to facilitate an evaluation of the surgical treatment of end stage hallux rigidus by means of Keller’s arthroplasty, implant arthroplasty or 1st MTP joint arthrodesis in a long established community based English NHS podiatric surgery service. End points for the evaluation were clinical and patient reported outcomes at six months following surgery.
The podiatric audit of surgery and clinical outcome measures (PASCOM-10) is a web-based audit and service evaluation instrument owned by the College of Podiatry (London, UK), provided as a service to its members [6]. PASCOM-10 captures patient data relating to their episode of care including; surgical data, outcomes, satisfaction and complications all of which can subsequently be reviewed via automated reports. The system was first conceived by Tollafield in 1994 [7] and the project went through several iterations before becoming an online tool in 2010, rebranded as PASCOM-10.
PASCOM-10 benefits from the inclusion of The Manchester Oxford Foot Questionnaire (MOXFQ) which has become a popular choice in the UK because it has been through a thorough development process including a relevant patient group, addressing concerns around construct validity [8]. The instrument has been through additional testing for responsiveness, minimal clinically important differences and comparison with previously well accepted instruments [8], [9], [10]. The PSQ-10 questionnaire also included in PASCOM-10 has been widely used to evaluate satisfaction with podiatric surgery and has been shown to be both reliable and repeatable but has not as yet been tested for validity [7], [11].
Section snippets
Method
The study design was a retrospective service evaluation utilising existing surgical audit data generated by and extracted from the PASCOM-10 online database. PASCOM-10 has an in built reporting package which is able to identify all patients relevant to the study. The system was fully implemented by the department in November 2011 with formal governance approval for its use. PASCOM-10 data collection begins when a patient is listed for surgical treatment and all consenting patients then
Results
Between 01/11/2011 and 31/10/2014, there were a total of 2221 admissions for podiatric surgery. Of these 157 admissions were for the treatment of end stage hallux rigidus. Table 1 below provides further demographic detail. Several patients in each group attended for surgery to both feet during the study period. The surgical procedures of interest were sometimes performed alongside other procedures (Table 2), all of which have the potential to influence outcomes. The Keller’s arthroplasty was
Discussion
The choice of surgical procedure for end stage hallux rigidus is often a difficult one and the decision must be made in partnership with the patient taking account of her expectations, activity levels, lifestyle and shoe choice. McNeil et al. in summarising the findings of their review were able to make grade B recommendations in support of arthrodesis but found insufficient evidence to support the use of either implant arthroplasty or Keller’s arthroplasty [16]. Several other studies have all
Declaration of interest
The author is a member of the PASCOM-10 working party, a clinician lead group which actively works on behalf of the College of Podiatry (London, UK) to develop and promote PASCOM-10. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
I would like to thank Mr. Matt Rothwell for his early support and guidance in developing this manuscript.
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