Development and Validation of the Foot Union Scoring Evaluation Tool for Arthrodesis of Foot Structures

Reliable evaluation of osseous consolidation after pedal arthrodesis can be difficult, and the presence or absence of radiographic healing often dictates care. Plain radiographs remain the mainstay imaging tool owing to their cost, efficiency, and low radiation exposure. Applying radiographic parameters that can reliably determine osseous healing is essential. However, currently, no reliable or validated measures are available to determine osseous union of any joint in the foot or ankle. The purpose of the present study was to develop a radiographic healing scoring system that would enhance the diagnostic healing assessment after joint arthrodesis of the foot or ankle. We adapted several existing scales previously validated for fracture healing in the leg, because no study has attempted to apply this to a joint fusion model. A total of 150 cases were evaluated by 6 blinded assessors to test the interrater reliability of the subjective healing assessment compared with the proposed scoring system. The radiographs were classified by the postoperative period: ≤4 weeks, 5 to 12 weeks, and >12 weeks. The initial proposed scale was found to have high interrater reliability but was burdensome. Using a priori item reduction protocols, a limited 5-item scale further improved the internal consistency and reduced the burden. The result was excellent interrater reliability (α = 0.978, standard deviation 0.02, 95% confidence interval 0.96 to 0.99) among all assessors compared with the reduced reliability (α = 0.752) for subjective arthrodesis healing. Intrarater reliability was also found to be superior using a test-retest method. The reliability of this system appeared superior to the subjective assessment of arthrodesis healing, even in the absence of clinical correlates, after foot arthrodesis.