A comparative prospective cohort health economic analysis comparing ankle fusion, isolated great toe fusion and hallux valgus surgery

David T. Loveday, Lynne V. Barr, Constantinos L. Loizou, Garry Barton, George Smith

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Background: This study assessed the health economics and outcomes of three common foot and ankle operations. 
Methods: Between July 2013 and October 2014 all patients undergoing ankle fusion (AF) for osteoarthritis, first metatarsophalangeal joint fusion for osteoarthritis (MF) or hallux valgus surgery (HV) were included. Patients having additional procedures were excluded. Patients completed the Manchester-Oxford Foot Questionnaire (MOX-FQ), the EuroQol EQ-5D-5L questionnaire and the EQ-VAS on presentation and at least 6 months post-operatively. 
Results: 63 patients undergoing AF (n = 22), MF (n = 22), or HV (n = 32) completed preoperative and postoperative questionnaires. 76 completed preoperative questionnaires and 63 completed the follow up questionnaires. The follow up questionnaires were completed at a median of 12 months (range 6-24 months) following surgery. The mean age at surgery was 59 years (range 26–85 years). Pre-operative MOX-FQ and EQ-5D-5L scores differed significantly between the three groups with AF and MF patients reporting worse scores compared to HV patients. MOX-FQ and EQ-5D-5L significantly improved in all groups from pre-operative levels. MOX-FQ: AF from 53.8 (CI 56.8–50.8) to 22.9 (CI 30.9–14.9), MF from 43.0 (CI 46.4–39.6) to 12.1 (CI 18.3–5.9), HV from 35.4 (CI 39.0–31.7) to 15.6 (CI 21.1–10.1). EQ-5D-5L: AF from 0.30 (CI 0.43–0.17) to 0.66 (CI 0.77–0.55), MF from 0.45(CI 0.52–0.38) to 0.83 (CI 0.90–0.76), HV from 0.71(CI 0.74–0.68) to 0.82 (CI 0.88–0.76). There was no significant difference in the EQ-VAS suggesting it may not be representative of foot and ankle health. Health economics analysis using the EQ-5D-5L data to estimate quality-adjusted life years (QALYs) suggested all three procedures were favourable compared to threshold levels of cost-effectiveness. There were differences in estimated costs between the three operations with AF at £2950 (threshold cost <£5400) and MF at £1197 (threshold cost <£5780) and HV varying from £625 to £1688 (threshold cost <£1640). 
Conclusions: This study reveals that the joint-specific (MOX-FQ) and generic health (EQ-5D-5L) outcome scores of patients improved after AF, MF and HV. The greatest benefit from surgery was gained in the arthritic patient groups. In the future, the use of large population patient reported outcome measures data may also potentially have implications for prioritisation of healthcare provision, acting as an indicator of foot and ankle surgical procedures that produce the most benefit to patients.
Original languageEnglish
Pages (from-to)54-59
Number of pages6
JournalFoot and Ankle Surgery
Issue number1
Early online date25 Nov 2016
Publication statusPublished - Feb 2018


  • foot
  • ankle
  • surgery
  • outcomes

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