Utilization of telemedicine for diagnosis and follow-up within foot and ankle orthopaedic surgery: A narrative review of the literature

Abstract

BACKGROUND:

Telemedicine has seen increasing adoption in healthcare over the past two decades, with proven clinical efficacy in several medical specialties. Orthopedics surgery has shown potential benefits from telemedicine implementation.

OBJECTIVE:

This review aims to evaluate the impact of telemedicine on clinical outcomes and patient and physician preferences in foot and ankle orthopedics, providing insight into the potential role of telemedicine within this subspecialty.

METHODS:

Multiple databases were searched for relevant articles on telemedicine in foot and ankle orthopedics. Inclusion criteria encompassed articles on telemedicine use and foot and ankle orthopedic care. Data included patient demographics, reasons for visits, duration of telemedicine, and outcomes. Analysis involved descriptive statistics, and a narrative approach to describe outcomes.

RESULTS:

Out of 218 articles, 12 met the inclusion criteria, comprising a total of 1,535 patients. Telemedicine visits were used for follow-up care, opinion consultations, monitoring, postoperative care, and treatment of various orthopedic conditions. Clinical outcomes demonstrated equivalence to in-person care. Patients expressed satisfaction with telemedicine but preferred in-person visits for future appointments. Physicians held neutral attitudes towards telemedicine, with concerns about the lack of physical examination.

CONCLUSION:

This review highlights the benefits of telemedicine in foot and ankle orthopedics. Telemedicine provides an alternative to in-person visits, improving patient access to care and offering cost and time savings. However, patient and physician preferences for in-person visits suggest a need to address concerns related to physical examination limitations. Telemedicine can supplement traditional care, but further research is required to explore its applicability in new patient consultations and optimize physician engagement.

1. Introduction

Over the last two decades, there has been a steady increase in the use of telemedicine to treat and communicate with patients [1]. In addition to the clear benefit of virtual visits, telemedicine has been shown to have equivalent clinical outcomes in numerous fields such as psychology, cardiology, respiratory conditions, and within certain orthopedic applications [2–5]. Telemedicine can be a great alternative to conventional in-person visits due to being cost-effective and with the recent shift towards virtual work environments. Orthopedic practice has been negatively impacted by the SARS-Cov-2 pandemic, thus demonstrating a large need for telemedicine use within orthopedics [6]. As telemedicine visits would promote cost-effective and clinically reliable care for patients, implementing telemedicine into orthopedic care would be incredibly beneficial [7].

Previous reviews have investigated telemedicine in the context of orthopedic and trauma surgery [2, 8], but no such review exists for foot and ankle orthopedics. While the benefit of telemedicine has been shown in other orthopedic subspecialties, foot and ankle care encompasses a much larger variety of treatment types. The large heterogeneity in foot and ankle care may better demonstrate the benefits of telemedicine, while also retaining a specific scope that is not diluted by studying orthopedic surgery in its entirety. While many reviews focused on the mostly follow-up telemedicine visits for various orthopedic conditions, this review aims to study initial foot and ankle consultations in addition to follow-up visits to fully understand where telemedicine fits within foot and ankle care from a purely clinical standpoint. Furthermore, a secondary objective of review was to collect data pertaining to patient and physician preference regarding telemedicine to understand if telemedicine can replace the tradition bedside manner and trust that an in-person visitprovides.

2. Methods

2.1. Study creation

This systematic review was performed in agreement with the most recent Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [9]. This systematic review was not registered prior to study completion, but search methodology was decided upon by foot and ankle orthopaedic surgeons prior to beginning the study. This study initial retrieved articles by searching PubMed, SPORTDiscus, CINAHL, MEDLINE, and Web of Science from database inception until July 8th, 2023. As the primary research question pertained to summarizing any studies related to telemedicine within foot and ankle orthopaedic surgery, the keyword search algorithm used in each database was (telehealth OR virtual OR telemedicine OR remote OR telephone) AND (foot and ankle orthopedic surgery OR foot and ankle orthopedics OR foot and ankle orthopaedics OR foot and ankle orthopaedic surgery).

2.2. Inclusion and exclusion criteria

Inclusion criteria were any article that reported telemedicine use in foot and ankle orthopaedics, included patients of any age, and had full-text. No specific inclusion criteria was defined regarding comparative groups or specific treatment interventions. Exclusion criteria was articles not containing any information related to foot and ankle orthopedics, prior systematic article, articles not related to telemedicine in any form, non-English articles, and articles without full-text.

2.3. Article screening process

This study utilized Rayyan, an online public website frequently used in the literature for systematic reviews [10]. A single author performed the screening process, with included/excluded articles being checked by two additional authors to ensure that all possible articles were included. First, duplicate articles were manually removed followed by article screening by abstract and title. Then, full-text article screening was performed for final article inclusion. After article inclusion, the references of the included articles were searched for additional articles that met the inclusion criteria.

2.4. Data extraction

Data extraction was performed by a single author. Data reported included first author, year of publication, number of total patients, number of patients receiving telemedicine or in-person visits, average patient age, number of male or female patients, type of visit (new patient or follow-up patient visit), reason for use, method of telemedicine, duration, patient preferences, physician preferences, and various outcome measures to assess the effectiveness of telemedicine visits in foot and ankleorthopedics.

2.5. Article quality grading

All observational studies included in this systematic review were graded for quality via the Methodological Index for Non-Randomized Studies (MINORS) [11]. The MINORS scale evaluates non-comparative studies on a 0–16 scale and comparative studies on a 0–24 scale with each item being worth 0–2 points each [11]. Article quality grading was completed by a single author.

2.6. Statistical analysis

The Statical Package for the Social Sciences (SPSS) version 29.0 (Armonk, NY: IBM Corp) was used for the statistical analysis of this study. Frequency weighted means and descriptive statistics were used to describe the demographics and outcomes from the included articles. Due to the heterogeneity of outcomes reported in the included articles, a narrative approach to systematic review was undertaken.

3. Results

3.1. Initial search results

A total of 12 articles were included out of 218 articles initially retrieved [12–23]. Summary of each included article can be found in Table 1. Refer to Fig. 1 for the PRISMA diagram for this systematic review. All 12 articles were graded via the MINORS scale with a mean score of 14.6 points (range: 10.0–22.0 points). Refer to Table 2 for more detailed information on the quality grading for each included article.

Table 1.

Summary of each included study with type of study, country, patient count, reason for visit, telemedicine delivery method, and study notes included

First Author (Year)	Article Type (Retro, RCT, Prospective, Case Series)	Country	Number of Patients	Type of visit (%)	Method of telehealth	Notes
Bisson (2021)	Retrospective	US	176	–	–	–
Cota (2017)	Retrospective	Ca-da	921	New patients with acute isolated orthopedic injuries = 921 (100)	E-mail only = 465 (50.5) Email and telephone = 456 (49.5)	–
Sharma (2022)	Prospective	UK	265	New patient = 41 (15.5) Follow up = 224 (84.5)	Telephone only	The saved travel time did not influence the patient’s choice (P = .73), nor the VAS score for the usefulness of the telephone consultation (Figure 1A; P = 0.30) The median time estimated as saved by not having to attend in person = 120 minutes VAS for the patient view of the usefulness of their telephone consultation (median)=9
Rhind (2021)	Cross-sectio-l observation study	UK	100	–	Telephone only	–
Labib (2021)	Retrospective	US	183	–	–	–
Crawford (2021)	Retrospective	US	11	New patients = 11 (100)	Videoconferencing technology and telephone	Virtual physical exami-tions were categorised based on the extent of manoeuvres performed and assigned a value ranging from 0 (no exam) to 3 (three or more manoeuvres performed). None (n = 131) One (n = 39) Two (n = 30) Three or more (n = 103) Total (n = 303)
Neville (2020)	Survey	US	–	–	Video=221 (92%) Facetime=85 (36%) Proprietary EMR or hospital platform = 71 (30%) Zoom=70 (29%) Doxy.me=56 (23%) Other platform = 47 (20%) WhatsApp=19 (8%) Skype=14 (6%) GoogleHangouts=11 (5%)	Informed patients about telemedicine = 221 (92%) Methods: Direct telephone call = 142 (59%) Email=78 (33%) Social media = 75 (31%) Other=56 (23%) Answering machine message = 34 (14%) Text=30 (13%) Physical mailer = 12 (5%)
Rajeev (2023)	Prospective	UK	426	New pt = 24 (5.2) Fracture pt = 52 (12.2) Follow-up=350 (82.2)	Telephone only	Suspended appointments means discharged with appointment open for 3 months if they had any symptoms Questions Extremely Satisfied (Score 5) Very Satisfied (Score 4) Satisfied (Score 3) Very Dissatisfied (Score 2)
Palmer (2021)	Prospective and retrospective patient selection	UK	25	Follow up (6– 8 weeks)=25 (100)	Telephone only	Contacted on the first attempt = 25 (48) Contacted on the second attempt.=10 (40) The remaining three patients (12%) Required 3 or more attempts to make successful contact = 3 (12)
Manz (2021)	Retrospective Cohort	US	216	New patient = 78 (36.1) Established complaint = 138 (63.9)	Tablet, computer, and/ or smartphone Zoom=212 (98.1) Phone call = 4 (1.9)	Note: Satisfaction was gauged with a Likert scale from 1 to 5, with 1 being extremely dissatisfied and 5 being extremely satisfied
Shah (2021)	Retrospective Cohort	UK	206	Follow up = 206 (100)	Telephone only	Stable patients = 100 Unstable patients = 106
Ahmed (2020)	Retrospective Cohort	UK	292	Follow up = 292 (100)	Mobile phones = 184 (63%) Landline=41 (14%) Did not pick up = 67 (22.9%)	–

Fig. 1.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram for this systematic review outlining the entire search process.

Table 2.

The Methodological Index for Non-Randomized Studies (MINORS) criteria for the twelve studies included in this systematic review

First author (year)	Study type	Total MINORS score	Clearly stated aim	Inclusion of consecutive patients	Prospective collection of data	End points appropriate to study aim	Unbiased assessment of study end point	Follow-up period appropriate to study aim	Less than 5% lost to follow up	Prospective calculation of the study size	Adequate control group	Contem-porary groups	Baseline equivalence of groups	Adequate statistical analysis
Bisson (2021)	Comparative	22	2	2	2	2	2	2	2	0	2	2	2	2
Cota (2017)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0
Sharma (2022)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0
Rhind (2021)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0
Labib (2021)	Comparative	18	2	2	2	2	2	0	0	0	2	2	2	2
Crawford (2021)	Non-comparative	10	2	2	2	2	2	0	0	0	0	0	0	0
Neville (2020)	Non-comparative	10	2	2	2	2	2	0	0	0	0	0	0	0
Rajeev (2023)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0
Palmer (2021)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0
Manz (2021)	Non-comparative	17	2	2	2	2	2	2	2	0	1	2	0	0
Shah (2021)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0
Ahmed (2020)	Non-comparative	14	2	2	2	2	2	2	2	0	0	0	0	0

3.2. Patient demographics

A total of 1,535 patients who received telemedicine for care related to foot and ankle orthopedics were included in this study. Patients (n = 1,535) had a frequency weighted mean age of 52.6±2.6 (n = 352, 22.9% of patients reported). The articles in this systematic review also included patients who were not seen via telemedicine for foot and ankle orthopedic conditions (n = 365). From this total patient count (n = 1900), there was a total of 1,627 patients (85.6% of patients reported) who were classified as either male or female with 615 males (37.8%) and 1012 females (62.2%). Furthermore, the article by Cota and colleagues (2017) examined 921 patients who received orthopedic care with some of the care being for foot and ankle orthopedic conditions. Of these patients receiving telemedicine care for foot and ankle orthopedic conditions with recorded visit type (n = 1,183), 179 patients (15.1%) had new patient visits and 1,004 patients (84.7%) had follow-upvisits.

3.3. Reason for telemedicine visits

Sharma and colleagues (2022) reported that 100% of their patients (n = 265) received telemedicine for opinions on foot and ankle pathologies in an elective manner [14], Rhind and colleagues (2021) reported that 64% of patients (n = 64) received telemedicine for monitoring, 33% for postoperative care (n = 33), and 3% (n = 3) for reporting test results [15]. Crawford and colleagues (2021) used telemedicine to communicate with all of their patients (n = 11) indications for foot and ankle surgical intervention [17]. Manz and colleagues (2021) reported that telemedicine for foot and ankle orthopedics was used in the treatment of deformity (n = 39 cases), dislocation (n = 5 cases), fracture (n = 57 cases), infection (n = 4 cases), neurologic pathology (n = 8 cases), arthritis (n = 37 cases), and soft tissue pathology (n = 66 cases) [21]. Ahmed and colleagues (2020) used telemedicine for foot and ankle orthopedic follow-up for patients who had injections (n = 44), received surgical intervention (n = 81), and were ”wait and see” (n = 167) [23].

3.4. Method and duration of telemedicine

The included articles had numerous methods of telemedicine including telephone, videoconferencing, Facetime, hospital platform systems, Zoom, and Doxy.me. Sharma and colleagues (2022) used telemedicine for foot and ankle orthopedic conditions with new patients receiving 30 minutes of telemedicine and follow-up patients receiving 15 minutes of telemedicine [14]. Palmer and colleagues (2021) reported that they used telemedicine visits lasting less than 10 minutes, including documentation time, for all of their new patients (n = 25) [20].

3.5. Assessment of telemedicine effectiveness

Sharma and colleagues (2022) reported that 13% of follow-up visits and 34% of new patient visits were ineffectual visits due to failure to reach the patient by telephone (n = 34 patients) and inappropriate discharge or referral (n = 5 patients) [14]. Rhind and colleagues (2021) reported excellent outcomes with 98% of patients reporting enough information was given, 100% of patients feeling involved, 97% of patients reporting that telemedicine was helpful, 95% of patients reporting that they knew how to contact if there was a problem, and 81% of patients understanding the role of the telemedicine in their care [15]. However, Rhind and colleagues (2021) reported that the physicians reported that the biggest limitations of the telemedicine was the inability to clinically examine a patient in person as well as patients not answering their phones [15]. Labib and colleagues (2021) found that there was no significant difference in the number of patients that reported excellent care depending on the method of healthcare delivery (in-person versus telemedicine, p = 0.37) [16]. The telemedicine group had 83.4% receiving excellent care and 89.2% of in-person patients receiving excellent care [16]. Neville and colleagues (2020) surveyed foot and ankle surgeons (n = 246 surgeons) who reported on the effectiveness (out of 10 points) on medication prescription (8/10), medical issues (7/10), dermatologic issues (7/10), musculoskeletal issues or tendinitis (6/10), post-operative care (6/10), preoperative surgical decisions (6/10), infection management (6/10), and trauma (5/10) [18].

Rajeev and colleagues (2023) reported that 85% of patients were either extremely satisfied or very satisfied with the wait time for the telemedicine visit, 95% were extremely satisfied or very satisfied with the ease of speaking to the physician, 87.5% were extremely satisfied or very satisfied with the ease of obtain information about the orthopedic care provided, and 100% were extremely satisfied or very satisfied with the ease of asking questions [19]. Furthermore, the financial cost savings was calculated to be $30,000 over the course of the study period by Rajeev and colleagues (2023) [19]. Palmer and colleagues (2021) reported that 44% of patients reported improvement in symptoms whereas 52% of patients reported no change in symptoms after telemedicine visit [20]. Manz and colleagues (2021) reported that 14.8% of patients needed help with Zoom for their telemedicine visit [21]. Crawford and colleagues (2021) reported that plans remained the same for 100% of patients (n = 11) from the telemedicine visit to the subsequent in-person visit [17]. Sharma and colleagues (2022) reported that the median time estimated to be saved via telemedicine visit was 120 minutes [14]. However, neither the saved time nor the pain score of the patient was associated with the perceived usefulness of the telemedicine visit (p = 0.73 and p = 0.30, respectively) [14].

3.6. Patient and physician preferences

Sharma and colleagues (2022) reported that 71.9% of patients would recommend a telemedicine visit to others based on their experience; however, 58.5% of patients would prefer an in-person visit for their next visit as compared to 4.3% of patients who would prefer a telemedicine visit for their next visit [14]. Similarly, Rhind and colleagues (2021) reported that 79% of patients would still prefer an in-person visit for their next visit despite the fact that 94% of patients were very happy or happy with their telemedicine visit [15]. Rajeev and colleagues (2023) reported that 95% of patients would recommend telemedicine visits for foot and ankle orthopedic conditions to their friends and family [19]. Manz and colleagues (2021) reported that 90.3% of patients would use telemedicine again despite 54.2% of patients would prefer an in-person visit for their next visit compared to 39.4% of patients who would prefer a telemedicine visit for their next visit [21]. Rhind and colleagues (2021) reported that 20% of physicians were very happy with telemedicine, 60% were neutral, and 20% were unhappy [15]. Neville and colleagues (2020) reported that only 52% of physicians believed that they could be able to triage emergencies via telemedicine in an effective manner [18].

For a summary of all results, see Table 3.

Table 3.

Summary of results across included studies

Study	Reason for Telemedicine Visit	Method and Duration of Telemedicine	Assessment of Telemedicine Effectiveness	Patient and Physician Preferences
Sharma et al. (2022)	Opinions on foot and ankle pathologies (100% elective)	New patients: 30 mins Follow-up patients: 15 mins	13% follow-up visits, 34% new patient visits ineffectual due to failed contact or inappropriate discharge/referral	71.9% patients recommend telemedicine, 58.5% prefer in-person for next visit
Rhind et al. (2021)	Monitoring (64%), postoperative care (33%), reporting test results (3%)	Varied methods: telephone, videoconferencing, Zoom, Facetime, etc.	Patients: Positive outcomes (98–100% satisfaction); Physicians: limitations in clinical examination and patient response	79% patients prefer in-person despite satisfaction with telemedicine; 20% physicians very happy with telemedicine
Crawford et al. (2021)	Communicate surgical intervention indications with all patients	Not specified	100% maintained same plans from telemedicine to subsequent in-person visit	Not specified
Manz et al. (2021)	Treatment of various conditions (e.g., deformity, fracture, infection)	Not specified	Some patients needed Zoom assistance (14.8%)	90.3% patients would use telemedicine again, preference split between in-person and telemedicine visits
Ahmed et al. (2020)	Follow-up for injections (n = 44), surgical intervention (n = 81), ‘wait and see’ (n = 167)	Not specified	Not specified	Not specified
Labib et al. (2021)	Not specified	Not specified	No significant difference in patient-reported excellent care between telemedicine and in-person	Not specified
Neville et al. (2020)	Effectiveness rating for various orthopedic issues by surgeons	Not specified	Mixed ratings for effectiveness on different issues via telemedicine	Only 52% physicians believed effective triage for emergencies via telemedicine
Rajeev et al. (2023)	Positive patient satisfaction, cost savings	Not specified	High patient satisfaction with wait time, ease of communication, and information accessibility; $30,000 cost savings	95% patients would recommend telemedicine; 100% extremely satisfied with asking questions

4. Discussion

In this systematic review, telemedicine use for foot and ankle orthopedics was organized and analyzed to understand both clinical and subjective preference to virtual visits. With the increase in remote work, healthcare restrictions, and social distancing that came as a result of the SARS-Cov-2 pandemic, one positive result was the increased infrastructure to support telemedicine [24]. As orthopedics is a specialty shown to benefit from telemedicine [2, 8], the primary objective of this present review was to understand the place of telemedicine care within the foot and ankle subspeciality.

Previous reviews have investigated telemedicine within orthopedic care with promising results [2, 8]. In the review by Peterson and colleagues, no significant difference was found for outcome parameters when compared to conventional in-person visits [8]. Most of the evidence favoring the use of telemedicine in orthopedics revolves around rehabilitation of knee arthroplasty [8], and no study to date has focused solely on foot and ankle orthopedics. As foot and ankle orthopedics includes many surgical and conservative treatment options, it could benefit greatly from both the consultation and rehabilitation aspects of telemedicine.

The primary objective of this review was to understand the impact that telemedicine has on foot and ankle orthopedic clinical outcomes, and good scientific evidence exists to support virtual visits. In one included study, no significant difference was found between in-person and telemedicine visits in terms of patient reported care [16]. For a study that involved telemedicine diagnosis followed by a subsequent in-person visit, no change in diagnosis was found [17]. A study by Palmer and colleagues found that a larger percentage of patients demonstrated no change in their pain symptoms (52%), whereas only 42% of patients within their cohort had an decrease in their painful symptoms [20]. However, all of the patients in this study were follow-up cases, meaning that initial diagnosis may have not been the issue. As a primary concern of telemedicine in various studies was the lack of physical examination when diagnosing conditions [8], these metrics likely fall in line with what would be found in an in-person clinical setting. Finally, when assessing clinical effectiveness, physicians found that medical prescription was the most effective (8/10), whereas treating traumatic foot and ankle conditions was found to be the least clinically effective (5/10). Interestingly, the physicians agreed that no difference in effectiveness for pre-operative or post-operative treatment was present for telemedicine (6/10). As the majority past telemedicine reviews have focused on post-operative care and demonstrate great results, it is promising that pre-operative assessment had similar clinical performance. However, as these surveys did not compare to in-person effectiveness by the same physicians, it is difficult to interpret the results without context of each clinical category’s respective in-person effectiveness. Future studies within telemedicine for foot and ankle orthopedics should directly compare effectiveness to in-person visits for better comparison of clinical outcomes. No negative results were reported regarding incorrect clinical assessment. As only 15.1% of our review cohort was comprised of new patients/consultations, more research into using telemedicine for purposes beyond follow-up visits would be beneficial to assess the true clinical diagnostic ability of telemedicine.

Secondary, it was of great interest of this review to understand physician and patient preference regarding telemedicine visits for foot and ankle orthopedic care. Regarding patient experience, most had positive opinions towards telemedicine treatment. As meeting with a physician virtually may not translate the same empathy and bedside manner that an in-person visit would have, studies still demonstrated that patients felt confident in asking questions and receiving quality care virtually [19]. While the positive clinical results of telemedicine are phenomenal, it is equally promising that patient care maintains the same level of professionalism that is found in an in-person setting. While many patients had positive experiences with telemedicine, many still stated that an in-person visit would be preferred [14, 15, 21]. While no study directly stated why patients would not prefer additional telemedicine visits, it can be inferred that it may be based on upon some of the technological challenges that many physicians faced in these included studies [15, 21]. From a physician perspective, the majority of physicians were neutral to the concept of telemedicine for orthopedic care [15]. Interestingly, the clinical category that physicians felt lacked in terms of quality of care (trauma orthopedics) was also low for physician reported confidence in treating (52% were confident) [18]. Meaning that while telemedicine may be a great tool for more predictive conditions, trauma orthopedics is likely better left for in person visits in term of both physician preference and quality of care. Finally, the only reported concerns that physicians had with telemedicine included failure to reach by telephone, technological issues, and lack of physical examination [14, 15]. As two of these concerns will likely improve over time with increases in technological awareness, telemedicine may become a more positive options for physicians.

As for some of the unexpected benefits of treating foot and ankle conditions using telemedicine, numerous studies stated improvements in time and cost savings [19, 20]. Not only were visits shorter, the waiting time was also found to be favorable for patients [19, 20]. While overall visit times were found to be longer for new patient visits when compared to follow-up visits [14], this would be expected in an in-person clinic as well. As time and cost savings are beneficial for both patients and physicians, telemedicine for orthopedic foot and ankle care is worth implementing into more cases.

While the SARS-Cov-2 pandemic made telemedicine visits a necessity, recent times allow for safe in-person visits. However, telemedicine demonstrated promising results in this review and should still be used in a clinical setting to increase clinic efficiency. For physicians interested in implementing telemedicine into their practice, Table 4 provides a summary of this review with suggestions for successful implantation.

Table 4.

Suggestions for successfully implementing telemedicine into orthopedic practice

Aspect	Suggestions
Clinical Outcomes	Utilize telemedicine for follow-up care, postoperative monitoring, and non-emergent cases, as evidenced by the positive patient-reported outcomes observed in the reviewed studies. Consider its application in preoperative assessments for less complex cases, where clinical examination might be less critical.
Patient Satisfaction	Recognize the patient satisfaction highlighted in the reviewed studies, particularly in terms of convenience and communication. Address patient concerns about the lack of physical examination by explaining the alternate diagnostic methods used during virtual visits and reassuring them of the diagnostic accuracy achieved.
Patient Preferences	Respect the preference of patients for in-person visits, especially for new patients and cases that necessitate thorough physical examinations. Offer a blended approach that combines telemedicine and in-person options to accommodate patient preferences while embracing the convenience of virtual consultations.
Physician Attitudes	Acknowledge the mixed attitudes observed among physicians towards telemedicine, as some expressed neutrality. Address concerns about physical examination limitations by providing guidelines for effective remote assessments and offering training sessions to enhance physician confidence.
Technological Support	Address the technological challenges highlighted in the studies by providing robust technical support and resources to ensure seamless telemedicine interactions. This includes both patient and physician training on virtual platforms.
Time and Cost Efficiency	Emphasize the time and cost-saving benefits of telemedicine, in line with the findings. Highlight reduced waiting times and convenience associated with virtual visits, showcasing how this approach enhances patient experience.
Future Research Opportunities	Encourage further research to explore telemedicine’s potential in new patient consultations and complex cases, considering the concerns of both patients and physicians. Investigate strategies to optimize virtual visits in terms of diagnostic accuracy and physician engagement.

Telemedicine in foot and ankle practice is a great option for rehabilitation visits post-operation. Numerous studies have demonstrated success in telemedicine for patients post-treatment or post-operation throughout all orthopedic specialties [25, 26]. For patients receiving foot and ankle care, virtual follow-up visits could be a viable option based on the success of telemedicine in other orthopedic subspecialties. Furthermore, this may allow for patients to receive care from a wider range of physicians, allowing for patients to opt for the best care possible.

We must address the limitations of this study. First, the type of telemedicine visit was not differentiated in terms of synchronous and asynchronous. As face-to-face virtual meetings are likely associated with higher patient perceived outcomes, future reviews should aim to differentiate. Furthermore, this review did not have enough cases to statistically differentiate the outcomes for new patients and follow-up visits. As new patients could have different impressions of a physician when meeting virtually when compared to patients who had an initial in-person consultation, it may have skewed patient reported outcomes to telemedicine. Next, our study was incapable of differentiating our patient cohort by occupation. Future studies should aim to study occupation with respect to telehealth visits within foot and ankle surgery. Future studies should aim to understand the true statistical difference between new patient and follow-up visits, particularly pertaining to patient reported and clinical outcomes. Finally, this systematic review included observational studies, which contain inherent biases that can skew results. Therefore, future studies should include randomized controlled trials in order to assess the effectiveness of telemedicine for foot and ankle orthopedics. Finally, our study did not utilize numerous data collectors when extracting and grading data. However, as stated in the methodology, potential articles were agreed upon by a minimum of two coauthors, with a third author mediating any possible conflicting opinions.

5. Conclusion

In conclusion, this systematic review provides valuable insights into the use of telemedicine for foot and ankle orthopedic care. The study demonstrates that telemedicine can be an effective alternative to in-person visits, with positive clinical outcomes reported for various orthopedic conditions. Patients expressed overall satisfaction with telemedicine, appreciating the convenience and ease of communication with healthcare providers. Despite positive patient experiences, a significant proportion of patients still prefer in-person visits for their next appointments. Physicians exhibited neutral opinions towards telemedicine, with concerns related to the inability to conduct physical examinations. Finally, telemedicine was found to be time-efficient and cost-saving, presenting additional benefits for both patients and healthcare providers. Overall, the findings suggest that telemedicine holds promise as a valuable tool within the foot and ankle orthopedic subspecialty, supplementing traditional in-person care and enhancing patient access to quality healthcare services.

Ethical considerations

Not relevant to this manuscript.

Informed consent

Not relevant to this manuscript.

Reporting guidelines

In agreement with the most recent Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [9].

Conflicts of interest

The authors declare that they have no conflict of interest.

Funding

The authors report no funding.