Papers by Judith Baumhauer
Foot & Ankle Orthopaedics, Oct 1, 2019
It is unclear whether patients attending physical therapy, post-op or for conservative care, achi... more It is unclear whether patients attending physical therapy, post-op or for conservative care, achieve clinically important differences (CID) on the patient reported outcome information system (PROMIS) scales. Key PROMIS outcomes physical function (PF) and pain interference (PI) match well with treatments provided in physical therapy. Physical therapy may also influence depression (Dep). Documentation of PROMIS outcomes associated with physical therapy are useful to help set patient expectations. The purpose of this analysis was to document expected PROMIS PF, PI, and Dep outcomes after physical therapy for foot and ankle diagnoses by 1) reporting average improvement and 2) examining whether severity of symptoms (PROMIS Scales) at the start of physical therapy are associated with a 0.5 standard deviation (CID) improvement at the end of therapy. Methods: PROMIS scales were available at the start and end of physical therapy treatment for 377 patients with foot and ankle ICD10 codes. Clinical categories(>n=20) of patients were identified for 6 groups(n=309): Achilles Rupture(n=24), Fracture(n=34), Ankle Pain(n=105), Foot Pain(n= 50), Ankle Sprain(n=51), and Achilles Non-Rupture(n=45). ANOVA models followed by pairwise comparisons were used to assess differences between start and end scores for all patients (n=377) and across diagnoses (n=309). Minimal CID was defined as improvement of t-score 3-5 and CID as above 5 (0.5 SD) consistent with published data. PROMIS scales were also converted to 0.5 standard deviation(SD) increments to document proportions of patients with symptoms relative to normal of the US population at start and end of physical therapy. Chi-square analysis was used to examine the association of PROMIS symptoms PF and PI at the start and end of care in 0.5 SD increments. Across ALL patients the largest improvements occurred in PF (6.5, p<0.01) followed by PI (3.9, P<0.01) and Dep (2.4, p<0.01). When evaluating diagnostic categories, all categories improved for PI (p<0.01), PF (p<0.05) and for Dep except for Ankle Pain (p=0.22). For PF, improvements ranged from 6.6 for Ankle Sprain to 3.3 for Achilles Non-Rupture. For PI improvements ranged from 11.1 for Achilles rupture to 4.6 for Achilles Non-Rupture. For both PF and PI there was a significant association of starting PF (p<0.01) and PI (p<0.01) score and end PF and PI scores. Patients with worse PF or PI in the midrange (55-65) at the start showed a higher percentage of patients achieving a 0.5 increment improvement at the end of therapy. Although many factors influence these outcomes, physical therapy for foot and ankle patients was associated with strong positive, clinically meaningful outcomes for a majority of patients as assessed during the episode of care. As expected improvements were greater for PF and PI as compared to Dep. Providers should consider more severe symptoms as a possible indication for physical therapy referral.
End stage arthritis of the first metatarsophalangeal joint has been treated surgically in the pas... more End stage arthritis of the first metatarsophalangeal joint has been treated surgically in the past by fusion and replacement. Fusion has remained the most commonly performed procedure and gives excellent pain relief but may interfere with activities in some patients. Joint replacement previously has had limited success. Problems include loosening, osteolysis, subsidence, and failure to regain motion. Osteolysis associated with wear debris has limited the success of silastic replacements. Polyvinyl alcohol (PVA) has shown promise as a material for hemiarthroplasty in the great toe. The material has better wear patterns than silastic and does not fragment. The hemiarthroplasty is inserted through a dorsal incision into a reamed bed in the first metatarsal head. The implant is available in two sizes, 8 mm and 10 mm. The PVA hemiarthroplasty has been the subject of a randomized controlled trial compared with fusion, with the results as yet to be published. Limited results to date have shown promise for this arthroplasty as an alternative to fusion for patients wishing to maintain joint motion and may avoid the fragmentation and loosening seen in prior replacements.
Journal of Patient-Reported Outcomes, May 27, 2020
Background: Research on outcomes after ankle fusion focuses on basic activities of daily living, ... more Background: Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient's perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication. Methods: This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120-365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points. Results: The linear mixed model analysis for PF after the 120-149 days, and for PI, after 90-119 days, indicated recovery plateaued at 39-40 for PF and 57-59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of -5.4 (95% CI -7.7 to -3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance. Conclusion: Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis. Level of evidence: Level II, prospective single cohort study.
Foot & Ankle Orthopaedics, Jun 1, 2018
Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling s... more Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intraarticular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.
Osteoarthritis and Cartilage, Aug 1, 2011
Objective: While recent evidence suggests that foot pain may be related to mechanical stress, qua... more 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 e 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 ManneWhitney 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. 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 pressureetime integral was positively associated with FFI-R Pain Subscale Score (r ¼ 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.
Clinical Orthopaedics and Related Research, Jun 1, 2016
Clinical Orthopaedics and Related Research, Aug 1, 2013
Health Systems, Dec 7, 2017
The objective of this research was to assess the implementation of collecting patient-reported ou... more 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.
Foot & Ankle Orthopaedics, Oct 1, 2019
Healthcare is at a unique time in history where patient reported outcomes have become important i... more Healthcare is at a unique time in history where patient reported outcomes have become important in assessing value and subsequent reimbursement with pay-4-performance initiatives. It is unclear whether physical function, pain and depressive symptoms can assist providers determine if additional physical therapy may improve care for foot and ankle patients considering post-op and/or non-operative care. The purpose of this research was to examine symptom severity (PROMIS PF, PI, and Dep) after surgery or with non-operative care at the start of formal physical therapy to determine if this symptom severity presentation and/or change in symptoms over time are predictors of improvement in physical function as assessed by PROMIS PF. Methods: PROMIS scales were available at the start and end of physical therapy treatment for 377 patients with foot and ankle ICD10 codes. The mean age (40.2±18.1 years), body mass index (BMI) (28.9±7.9 kg/m2), and proportion of females (62.1%) were recorded. The median number of physical therapy visits was 5 (interquartile range=5). Clinical categories of greater than 20 were identified for 7 groups including: Achilles rupture (n=24), Fracture (n=34), Ankle Pain (n=105), Foot Pain (n= 50), Ankle Sprain (n=51), Achilles Non-Rupture (n=45) and Other (n=68). Two multivariate linear regression models; 1) solely using data available at the start of therapy (age, gender, BMI, diagnosis category, PROMIS scores at the start of physical therapy); And, 2) a second model adding change in PROMIS PI, DP and completed visits to model 1 were examined for their ability to predict change in PF (Start to end of physical therapy). : The average change in PROMIS PF was 6.5±8.8 with a range of -20 to 49.1. Correlations of PROMIS scales at the start of therapy with change in PROMIS PF were r-values <0.48. Correlations among change in PROMIS PI and Dep with PF scales were rvalues <0.38. The first model predicting change in PF based on available data at the start of physical therapy included PROMIS PF(p<0.01), PI(p<0.01) and Dep(p=0.03) at the start of physical therapy (r-value = 0.58 an r-value increase of 0.1 over univariate correlations). No other variables were significant. The second model included PROMIS PF(p<0.01), PI(p<0.01) and Dep (p=0.05) and change in PI(p<0.01), Dep(p=0.01) and visits completed (p<0.01) achieving an r-value = 0.75 (an r-value increase of 0.27 over univariate values) (Figure 1). Providers should consider patients who present with more severe symptoms as good candidates for formal physical therapy. Positive trends during therapy suggest that patient may continue to improve. Severity of PI and Dep at the start of PT were independent predictors of improvements in PF. Using PROMIS assessments, appropriate referrals can be made to physical therapy to improve physical function and add value to the health of our patients.
Clinical Orthopaedics and Related Research, Apr 1, 2016
Journal of Foot and Ankle Research, Sep 1, 2008
Foot & Ankle Orthopaedics, Sep 1, 2017
Introduction/Purpose: A prospective, randomized, non-inferiority clinical trial demonstrated that... more Introduction/Purpose: A prospective, randomized, non-inferiority clinical trial demonstrated that first metatarsophalangeal joint (MTPJ1) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant (Cartiva®) had equivalent pain relief and functional outcomes to MTPJ1 arthrodesis at 2 years. Despite 91% success, there was a 9.2% rate of implant removal and conversion to fusion. Other implants with more bone resection have demonstrated poorer outcomes after conversion to fusion than if a primary arthrodesis was performed. Since bone loss with synthetic cartilage implant hemiarthroplasty is minimal, we hypothesized that outcomes following implant removal and conversion to fusion would be similar to those following primary arthrodesis. We determined the outcomes of revision of synthetic implant hemiarthroplasty of the great toe to MTPJ1 arthrodesis and compared these outcomes to the primary arthrodesis cohort. In the original pivotal trial, 152 patients >/=18 years diagnosed with hallux rigidus grade 2, 3, or 4 underwent synthetic cartilage implant MTPJ1 hemiarthroplasty, as previously described (Baumhauer et al., Foot Ankle Int. 2016;37(5):457-69). Outcome measures including the Foot and Ankle Ability Measure (FAAM), pain visual analogue scale (VAS), and Short Form-36 Physical Functioning (SF-36 PF) score were obtained preoperatively, and at 2 weeks, 6 weeks, and 3, 6, 12 and 24 months postoperatively. Revision surgery of the MTPJ1 was performed using the original surgical incision. The medial and lateral capsule was released, the metatarsal head was exposed to permit implant removal, and the void was filled with cancellous autograft or bone graft substitute. Joint compression was achieved using two crossed screws or a compression plate. Patients were non-weightbearing for six weeks. Union was confirmed on radiographs. Patients were followed post-conversion and assessed for pain and functional outcomes. Results: Fourteen patients (9.2%) underwent implant removal and conversion to MTPJ1 arthrodesis. Mean time to revision surgery was 12.8 (range: 1.8-24.2) months. The removed implants demonstrated no signs of wear, fragmentation, fracture or other defects; the cause for failure was patient-reported pain. Eleven revision patients were followed up for mean 11.6 (range 3.1-22.9) months. Pain VAS decreased by mean 65.2 (range: 19.5-96.0) mm from baseline (i.e., prior to implant hemiarthroplasty). The FAAM ADL and Sports scores increased by mean 39.0 (range: 2.4-73.8) points and 49.2 (range: 5.8-90.6) points, respectively (Figure ), compared to baseline, with minimal clinically important differences (MCIDs) of 8 and 9 points, respectively. The SF-36 PF subscore improved by mean 37.8 (range: 10-65) points from baseline, with MCID of 3.3 points. Patients who underwent implant removal and conversion to MTPJ1 arthrodesis exhibited outcome measure scores statistically similar (p>0.05 for all scores) to those of the MTPJ1 fusion cohort at 24 months in the original pivotal trial (Figure ). These results indicate that removal of the synthetic cartilage implant does not "burn a bridge" to having excellent pain relief and a successful functional outcome with a subsequent fusion procedure, if needed. The amount of bone loss with synthetic implant hemiarthroplasty is minimal, as the original joint surface length is maintained.
The OFAR Experiment: Barriers, Lessons, and Findings From an Orthopedic Patient Outcomes Database
Foot & Ankle Orthopaedics
Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: As digital healthcare sy... more Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: As digital healthcare systems advance, patient reported outcomes (PRO) platforms offer an effective strategy for clinicians to evaluate patient relevant treatment outcomes. Initiated by AOFAS in 2018, the Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network was a multi-center surgical outcomes registry platform established to collect, aggregate, and report PRO data. OFAR included surgical information, patient demographics, and PRO instruments developed by the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS). Due to high costs and competing technologies, OFAR data collection ended in 2020. Although OFAR did not achieve widespread and sustained use, a large number of patients were enrolled over the 2-year period. We hypothesized that each aggregated PRO metric improved at all post-operative time points compared to preoperative values. Methods: From 2018-...
Frontiers in Psychiatry, 2022
Background: Patient-reported outcomes (PROs) can promote person-centered biopsychosocial health c... more Background: Patient-reported outcomes (PROs) can promote person-centered biopsychosocial health care by measuring outcomes that matter to patients, including functioning and well-being. Data support feasibility and acceptability of PRO administration as part of routine clinical care, but less is known about its effects on population health, including detection of unmet healthcare needs. Our objectives were to examine differences in rates of clinically significant depression across sociodemographic groups and clinical settings from universal depression screens in a large health system, estimate the number of patients with untreated depression detected by screenings, and examine associations between biopsychosocial PROs—physical, psychological, and social health.Methods: We analyzed data from over 200,000 adult patients who completed depression screens—either PROMIS (Patient Reported Outcomes Measurement Information System) or PHQ-2/9—as part of routine outpatient care.Results: Depres...
This Users' Guide will facilitate integration of patient-reported outcomes (PROs) in the elec... more This Users' Guide will facilitate integration of patient-reported outcomes (PROs) in the electronic health record (EHR), enabling use of PRO data for multiple clinical, research, and administrative applications, and thereby promoting patient-centered care.
Foot & Ankle Orthopaedics, 2020
Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: A rece... more Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: A recent survey of 100 international foot and ankle orthopaedic surgeons revealed that patient age greater than 60 years is not considered to be a significant risk factor for nonunion following foot and ankle arthrodesis. This finding was surprising as published basic science research shows that autologous bone graft used during fusion surgery may be less effective when harvested from older patients due to both diminished osteogenic potential and migration capacity of mesenchymal stem cells. The purpose of this study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis. Methods: A Level 1 clinical trial was performed comparing fusion success in 397 hindfoot or ankle arthrodesis subjects (597 joints) supplemented with either autograft or an osteoinductive recombinant human protein derived growth factor (rhPDGF- BB/β-TCP) bone graft su...
Foot & Ankle Orthopaedics, 2020
Category: Midfoot/Forefoot; Other Introduction/Purpose: Synthetic cartilage implants for first me... more Category: Midfoot/Forefoot; Other Introduction/Purpose: Synthetic cartilage implants for first metatarsophalangeal osteoarthritis have been used for nearly a decade with Level 1 clinical evidence showing 84.9% of implants remain in place at a mean follow-up of 5.8 years. In contradiction to these positive results, however, some recent publications have shown higher revision rates and attempted to correlate the need for revision with the postoperative joint space interval. Most of these studies performed assessments based off of routine anterior-posterior (AP) radiographs using hand drawn measurements without image calibration or scaling. The purpose of this independent radiographic review was to further explore any relationship between joint space integrity and the need for revision surgery. Methods: An independent radiographic review by two board-certified, fellowship-trained, practicing musculoskeletal radiologists with no competing financial interests was conducted for 15 subject...
Foot & Ankle Orthopaedics, 2018
Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions acco... more Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions accounting for 25% of musculoskeletal injuries. Prior reports have found increased risk of failed lateral ankle reconstruction in those with a subtle cavus deformity, and therefore, correcting the deformity is often advocated. However, other studies have been unable to identify subtle cavus deformity as a clear risk factor for recurrent injury. The purpose of this study was to 1) compare PROMIS physical function (PF), pain interference (PI), and depression scores in patients with subtle cavus deformities to those without deformity who underwent lateral ankle ligament reconstruction, 2) compare PROMIS scores in allograft and modified Brostrom-Gould (BG) reconstructions in those with subtle cavus, and 3) to evaluate for any post-operative complications in those with subtle cavus. Methods: PROMIS CAT scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic...
Foot & Ankle Orthopaedics, 2019
Category: Ankle Arthritis Introduction/Purpose: Much research on outcomes after ankle fusion focu... more Category: Ankle Arthritis Introduction/Purpose: Much research on outcomes after ankle fusion focuses on gait changes, progression of adjacent joint arthritis, and other clinical measures, but little has been reported on the patient’s perspective. The purpose of this study was to determine the change in physical function and pain after undergoing ankle arthrodesis as determined by patient reported outcomes (PROs). Methods: This was a retrospective review of prospectively collected patient reported outcomes data in 88 consecutive ankle arthrodesis procedures performed from May 2015 to March 2018. Patient reported physical function (PF) and pain interference (PI) were measured as part of the routine care via the PROMIS computerized adaptive test at 6 months and 1 year post- operatively. Descriptive data and Spearman correlations were determined for PF and pain at 6 months and 1 year. Results: The mean pre-operative PF T-score was 37, less than the pre-determined threshold value of 42, ...
Foot & Ankle Orthopaedics, 2019
Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: Diabetic foot ulcers (DFU) with deep i... more Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: Diabetic foot ulcers (DFU) with deep infections and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation is challenging, and is a complex decision based on the patient’s function at baseline, extent of infection, vascular patency and comorbidities. Although Chopart amputation preserves greater limb length than Syme amputation, additional procedures, such as Achilles tenectomy and tendon transfers are necessary to optimize residual foot function. Challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes including patient reported outcomes of Chopart and Syme amputations. Methods: A query utilizing current procedural terminology (CPT) codes was performed to identify patients who had undergone Syme or Chopart amputations for diabetic foot infections by an academic orthopaedic group between Augu...
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Papers by Judith Baumhauer