Do Custom Orthotics Help Improve Pain and Function in Patients with Progressive Collapsing Foot Deformity

CATEGORY: Hindfoot INTRODUCTION/PURPOSE: Progressive collapsing foot deformity presents with pain, deformity and functional limitations affecting quality of life. The prevalence of this condition ranges from 3-10% depending on the age and sex of the patient. Sixty percent of patients have concurrent medical problems that may delay or limit the ability to undergo surgical intervention. Non-operative treatments such as ankle bracing or custom orthotics are costly and their value to improve pain and function has not been examined with validated patient-centered instruments, specifically patient reported outcome measures. The purpose of this study was to assess if use of a modified UCBL orthosis improved PROMIS pain interference (PI) and physical function (PF) in patients with progressive collapsing foot deformity (PCFD). METHODS: Prospective PROMIS data (PF, PI) was obtained from 2015 to 2020 for all patients who obtained a modified UCBL orthosis for PCFD. Patients with PROMIS data pre- and post-obtaining an orthotic with a minimal follow up of 90 days were included. Patients who elected to pursue operative treatment after receiving the orthotic were noted using CPT codes. Patients without complete evaluations were excluded (Figure 1). The primary outcome was PROMIS Scores (PF and PI) before and after orthotic usage. Covariate analysis included patient demographics including age, gender, marital status, race and ethnicity, and orthotic laterality. We estimated separate mixed effects linear regression models with patient random effects for each PROMIS outcome. RESULTS: There were 282 patients included in our cohort with an average age of 57 years. 61% were female and 87.8% were White. Patients had an average follow-up of 467 days +/- 366. Multivariate analysis indicates that there was a 0.94 decrease in PROMIS PF t-score relative to orthotic usage at final follow up (p = 0.035 +/- 7.47) with an increase of 0.76 PROMIS PI t-score (p value = 0.085 +/- 7.40). Despite limited measureable impact on PROMIS outcomes using custom orthotics, only eleven patients subsequently pursued surgery and underwent operative fixation at an average of 461 days after initial evaluation. There were no differences in regard to race, ethnicity or orthotic laterality and PROMIS scores. CONCLUSION: Publications have focused on outcomes of operative treatment for FCFD, with few examining orthotics. Our study demonstrates a lack of pain and functional improvement with a modified UCBL questioning the potential value of this costly item. However, despite this only 3.9% of patients subsequently underwent surgery. This work raises additional questions: 'What does the patient hope to improve with treatment?' 'What is the role of risk assessment in patients considering treatment choices?' Patient reported outcomes can be used in shared decision making, not only to align expectations, but also when allocating healthcare dollars to durable medical goods.