AAOS Now

Published 10/1/2014

AOFAS Joins Choosing Wisely Campaign

Releases list of 5 common, but often unnecessary, tests, procedures

The American Orthopaedic Foot & Ankle Society (AOFAS) has followed the lead of the AAOS and the North American Spine Society to become the third orthopaedic society to join the Choosing Wisely Campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation designed to advance medical professionalism in clinical practice.

“Our participation in Choosing Wisely is aimed at defining appropriate care for patients with conditions of the foot or ankle,” said Sandra E. Klein, MD, chair of the AOFAS Evidence-Based Medicine Committee. “The AOFAS recommendations provide valuable information to help patients talk with their orthopaedic surgeons and make the best choices about their treatment.”

Making decisions about foot and ankle care is a process that should involve the patient and an orthopaedic foot and ankle specialist. To help encourage positive conversations in the exam room, the AOFAS listed the following five recommendations regarding tests/procedures that are commonly ordered but not always necessary:

  • Don’t perform surgery for a bunion or hammertoes without symptoms. Foot surgery for cosmetic reasons is not supported by medical research. Symptoms such as pain and limitations of activity are the most common reasons to pursue bunion or hammertoe surgery. Patients having surgery for bunions and hammertoes are at risk for a wide range of complications such as nerve damage, infection, bone healing problems, and toe stiffness.
  • Don’t use shoe inserts for symmetric flat feet or high arches in patients without symptoms. Symmetric flat feet or high arches are common conditions, and generally they are asymptomatic. The development of the arch is not related to external supports, and no evidence exists that any support is needed in asymptomatic patients.
  • Don’t perform surgery for plantar fasciitis before trying 6 months of nonoperative care. With 6 months of consistent, nonoperative treatment, plantar fasciitis will resolve up to 97 percent of the time. Surgery has a much lower rate of success and has the added possibility of postoperative complications.
  • Avoid X-ray evaluation of the foot and ankle without standing (weight bearing) in the absence of injury. The functional position of the foot and ankle is one of weight bearing. When compared to non–weight-bearing X-rays, deformities of the forefoot, midfoot, and hindfoot have been shown to increase on weight-bearing X-rays. In addition, narrowing of the ankle joint space on standing X-rays is associated with symptoms of arthritis. Therefore, weight-bearing X-rays, when possible, give the most accurate assessment of the functional bony anatomy of the foot and ankle.
  • Don’t use alcohol injections for Morton’s neuromas. Alcohol can permanently damage the nerve, but without effective pain relief. At 5-year follow-up, alcohol injection for Morton’s neuroma has both a high recurrence rate and a high rate of complications, including bruising, scar formation, dysesthesia, severe pain and infection.

Developing the list
The AOFAS Choosing Wisely list was developed after months of careful consideration and review. To formulate the list, the AOFAS Evidence-Based Medicine Committee reviewed the society’s position statements on foot and ankle care and solicited expert opinion from specialty leaders, including the AOFAS board of directors. It then prepared an initial list of topics for the board’s review. The board approved five statements for further development.

Committee members then reviewed the scientific literature on each statement and presented draft statements with supporting evidence to the committee for discussion. They also reviewed the Choosing Wisely campaign website (www.choosingwisely.org) to ensure that the proposed content was not duplicated in other lists. The committee evaluated each statement and edited the statement wording and supporting references. Once consensus was reached, the 2014 list was finalized by committee members and reviewed and approved by the AOFAS Board of Directors.

“Media has often criticized participating societies for submitting recommendations that avoid hurting their members’ income,” noted AOFAS Past President Steven L. Haddad,MD. “This list has four of the five points directly affecting the pocketbooks of our surgeons. I am proud to say our Society has taken the high road and will provide meaningful public education supporting diagnosis and management options in patients’ best interest. Media scrutiny can only generate a positive response.”

First announced in December 2011, Choosing Wisely is part of a multiyear effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite healthcare resources. Participating specialty societies are working with the ABIM Foundation and Consumer Reports to share the lists widely with their members and convene discussions about the physician’s role in helping patients make wise choices.

To date, nearly 100 national and state medical specialty societies, regional health collaboratives, and consumer partners have joined the conversations about appropriate care. The Choosing Wisely campaign also continues to reach millions of consumers nationwide through Consumer Reports and other consumer and advocacy partners. For support statements on each recommendation, visit the Choosing Wisely page at the AOFAS website (www.aofas.org).