The Influence of Preoperative Deformity Severity in Postoperative Patient Reported Outcomes in Adult Acquired Flatfoot
Authors: Chrea Bopha , Netto Cesar de Cesar , Garfinkel Jonathan H. , Day Jonathan , Saito Guilherme H. , Li Shuyuan , Lintz Francois , Deland Jonathan T. , Ellis Scott J. 
Published: November 2020

Category: Ankle; Hindfoot; Other Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a complex deformity. Previous work has demonstrated correlation between postoperative foot alignment and patient-reported outcomes. While this work has provided essential targets for surgeons performing flatfoot reconstruction, there is an absence of data that would enable surgeons to predict which patients are likely to have greater or less improvement after surgery based on their preoperative deformity. Conventional radiographs alone may not provide enough detail to isolate individual elements of the deformity. Weightbearing CT (WBCT) allows for far more precise analysis in this regard. We hypothesized that there would be a set of parameters defining preoperative alignment on WBCT that would predict which patients are at risk for a lower magnitude of postoperative improvement in patient-reported outcomes (PROs). Methods: In this retrospective IRB-approved study, patients that underwent surgical flatfoot reconstruction after having a preoperative standing WBCT were identified. Preoperative WBCT images were evaluated by two independent/blinded observers. Multiple parameters related to preoperative alignment and AAFD severity were measured in the sagittal, coronal and transverse planes. Parameters measured included talus-first metatarsal angle; distances between the floor and the navicular, medial cuneiform and cuboid; subtalar joint horizontal angle; superior talar - inferior talar angle; subtalar joint subluxation; talonavicular uncoverage angle; hindfoot moment arm (HMA); and foot and ankle offset (FAO). Prospectively collected data regarding preoperative and postoperative PROs was evaluated. Six PROs components were assessed: physical function; pain interference, pain intensity, global mental health, global physical health and depression. Multivariate regression analysis and a partition prediction model were used to assess the correlation between preoperative alignment and improvement in PROs. P-values of less than 0.05 were considered significant. Results: A total of 51 patients with a preoperative WBCT and postoperative PROs scores were identified and included. Demographic data is shown in Table 1. Multivariate regression analysis demonstrated that preoperative alignment significantly correlated with improvement in three out six components of PROs: pain interference, pain intensity and global mental health. The strongest predictor of improvement in PROMIS physical function t-score was medial cuneiform to floor distance, for pain interference t-score: cuboid to floor distance, for pain intensity: subtalar joint subluxation, for depression t-score: superior talar - inferior talar angle, and for global physical and mental health t-scores: sagittal talus-first metatarsal angle. Conclusion: Our analysis yielded readily identifiable cutoffs for WBCT measurements, where values above or below were correlated with significant differences in the magnitude of PRO score change. Interestingly, measures of sagittal plane collapse and hindfoot valgus were the most predictive of score changes. This data provides useful information for surgeons counseling patients prior to flatfoot reconstruction. Future work using this data to develop prediction models for postoperative outcomes would be valuable, as would studies using WBCT to evaluate the relationship between postoperative corrected alignment and PROs. Complete results are shown in the attached Table.