CORR Insights®: Is a Three-component Video-based Version of the Foot Posture Index Valid for Assessing Pediatric Patients With Orthopaedic and Neurologic Foot Conditions?

Where Are We Now?

Traditionally, orthopaedic clinical evaluation has relied on tangible input, including inspection, palpation, passive- or active-assisted ROM, and a combination of special tests [1, 2]. More recently, there has been a substantial emphasis on virtual clinical evaluation and exam documentation. Because of this, virtual clinical assessment models have been widely incorporated into institutional practices and advertised as an alternative to the decades-old examination doctrines—sometimes without proper validation.

For that reason, the study in this issue of Clinical Orthopaedics and Related Research® by Rethlefsen et al. [6] is so important. The authors reviewed their results with what had been an in-person-based assessment tool, the Foot Posture Index (FPI)-6, which they modified into a simplified version applicable for virtual examination and documentation of physical findings. They found that the FPI can be effectively modified for virtual use as an inspection-based, three-element metric (FPI3) assessed via live or recorded video, and they found that this approach is valid; specifically, it maintained acceptable correlation with its full six-element, in-person counterpart (the FPI6), and it demonstrated good interobserver reliability.

However, it is critical to note that with the conversion to a “skeletonized” visual-based metric, standardization in video capture becomes of utmost importance. In Rethlefsen et al. [6], video capture was performed in a standardized fashion by trained providers. This may differ from the routine virtual exam implemented in most institutions, where untrained patients communicate with providers using a broad spectrum of devices and in heterogenous settings. Notably, several authors have previously proposed viable solutions to such challenges, ranging from mailed instructions, to institutionally provided devices, and to evaluating patients virtually in standardized community hubs established explicitly for such purposes.

This work elevates the body of evidence, facilitating reproducible, evidence-based virtual clinical assessment and research documentation. It converts what may have long been an expert opinion–based realm into much-needed evidence-based practice. Based on these discoveries, surgeons might create virtual scoring systems or examination methods, which they then should validate the sensitivity and specificity of compared with classic clinical examinations regarding their ability to diagnose and help with clinical decision-making and treatment planning.

Where Do We Need To Go?

There are many orthopaedic scores that are widely used to gauge a spectrum of clinical and patient-reported outcomes. The work at hand is an extension of a current trend aiming to modify, abbreviate, and validate versions of established scoring systems. This is done with the aim of achieving ease of dissemination and use, subsequently improving the proportion of data capture and mitigating attrition or loss to follow-up. This line of work holds great potential, and we would all benefit from future inquiry on this theme.

Furthermore, the modified FPI3 used by Rethlefsen et al. [6] was implemented to assess foot posture among patients with cerebral palsy and Charcot-Marie-Tooth disease. Future research must determine whether the modified virtual version of the aforementioned modified score holds the same validity and interobserver reliability when testing for a wider variety of foot conditions, including those of a predominantly planovalgus deformity.

It is important to note that the study by Rethlefsen et al. [6] outlines a framework for validating remote assessment tools across various clinical domains, and this framework should be useful far beyond the subspecialty of foot and ankle surgery. Future directions can include evaluating the reliability of modified virtually captured scores in predicting clinical and patient-reported outcomes compared with their in-person counterparts. Furthermore, studying the costs and workflows used for virtual assessment incorporation into research trials, as well as overall episode-of-care expenses, will be very important. Even though we all hoped that virtual clinic visits would prove cost effective, preliminary work suggests that this may not be true [4]. Future studies need to confirm or refute this contention.

How Do We Get There?

In the coming years, we may witness the emergence of virtual platforms that are capable of offering haptic feedback and more-advanced video systems. These might help provide physicians with a more comprehensive overview than what is currently possible using the conventional smart devices that are widely utilized today. The work done by Rethlefsen et al. [6] in modifying the FPI is a strong example of innovation in response to the evolving landscape of research and clinical practices.

Based on current and past trends, I expect that telemedicine tools will continue to be integrated into mainstream clinical practices and research, driven by the need to improve access, maintain a cost-effective healthcare system, enhance patients’ experience, and streamline providers’ workflow. Providing tools to accurately diagnose, treat, and predict outcomes among patients who cannot—or would rather not—be evaluated in-person will be crucial in ensuring safe and reliable healthcare provision. One way to achieve this goal is to create more virtual clinical examination checklists and methods for every joint or anatomical region or disease. Researchers would then need to validate the sensitivity and specificity of these methods in relation to classic in-person clinical examination methods regarding how well they achieve the right diagnosis, clinical assessment, and treatment plan.

Read This Next

Recent studies have clarified the efficacy of telehealth examinations compared with traditional, in-person clinical assessments across various medical disciplines:

• This comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology demonstrates that audiovisual telehealth assessments can yield clinically reliable conclusions comparable to in-person examinations [1].

• A paper evaluating agreement between telehealth and in-person assessments of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic highlights the reliability of telehealth in clinical assessments for diagnosing and devising treatment plans for chronic musculoskeletal conditions [2].

• This prospective, randomized clinical trial validates the reliability of audiovisual postoperative follow-up after hip and knee arthroplasties [5].

• Additionally, the principles of virtual orthopaedic assessment presented in this book are a guide for clarifying the technical and clinical intricacies pertaining to the use of telehealth in orthopaedic clinical assessments across various anatomical regions and orthopaedic conditions [3].