The aim of this study was to provide, for the first time, an agreed set of research priorities for the UK podiatric surgery profession to facilitate a long-term research strategy. This work was undertaken to meet the NHS research agenda and there was an identified gap in the four recently published foot-related research priorities from 2019 to 2022 [7, 9,10,11]. The initial scoping exercise identified key research themes, topics, and questions to form the consensus voting completed at the annual podiatric surgery conference. The strength of this study was the participation of 101 delegates at the national conference who have determined the future research priority questions and topics: shaping the future research strategy for the Podiatric Surgery profession.

The highest priority theme identified in the consensus voting was ‘health economics and service delivery’. Within this theme, service delivery was ranked the highest priority topic, despite this none of the questions within this topic reached the minimum agreement threshold. Interestingly, the highest scoring question came from the second-ranked topic within the theme of ‘health economics and service delivery’ and achieved high consensus: ‘How does podiatric surgery benefit the health of the population?’. Participants appeared to feel strongly that the benefits of podiatric surgery services on public health were important, especially considering this was ranked among the most highly-scoring questions overall. It is noted this theme is not included in the other foot related research prioritisation strategies [7, 9,10,11,12].

The second highest theme was ‘treatment’. Within this theme, surgical management of the forefoot was the highest priority topic and was one of only two areas within the whole priority voting to achieve high agreement levels with a score of 78%. This is unsurprising considering the prevalence of forefoot pathology in the foot and the frequency of hospital referrals [13, 14]. Although forefoot surgery was ranked the highest priority topic, none of the questions reached the pre-agreed consensus level, potentially demonstrating a broader scope of interest amongst the delegates across the individual questions included. However, another explanation could be that there were more questions to select from in the forefoot topic (six versus three to four in the other topics), therefore reducing the likelihood of agreement. Interestingly, the third-placed, midfoot topic produced the highest scoring research question of this theme: ‘what is the most effective Lapidus fixation option?’ with a score of 62%.

Limb salvage surgery ranked third in the theme priority voting, potentially reflecting the number of emerging podiatric surgery units currently involved in management of this patient cohort. There is a growing number of podiatric surgery centres that are becoming involved in the surgical management of the diabetic foot, forging relationships with other professions, and championing multi-disciplinary team working to reduce tissue loss and amputation. Encouraging multi-disciplinary working was also noted as a priority within the vascular priorities project to improve patient outcomes [11], and since the covid-19 pandemic podiatric surgeons have been increasingly recognised as key members in the limb salvage team [15, 16]. Despite this, a possible explanation for the low ranking of this theme is that not all podiatric surgery centres in the UK are undertaking limb salvage surgery at the present time. This, however, may change in the future due to the ever-increasing population with diabetes [17] and the growing recognition for podiatric surgery specialism within limb salvage [18, 19].

Collecting patient reported outcome measures are a valuable part of podiatric practice in demonstrating both the efficacy and scope of surgical intervention. PASCOM-10 is a national database used widely within podiatric surgery since May 2010. This collates a range of pre- and post-operative information. It is used by podiatric surgeons and podiatrists for assurances and governance regarding patient outcomes and patient safety. Given the wide use of PASCOM-10 and the known importance of demonstrating patient outcomes, it was interesting that this theme was voted the lowest priority. A possible explanation of this is that it may be seen as a fundamental part of day-to-day surgical practice. The highest scoring research question: ‘how does quality of life improve after foot surgery?’ is something that PASCOM-10 data does not directly collect. Another reason for quality of life scoring particularly highly compared to other themes and topics may be due to the low number of topics and questions within the theme, therefore increasing the chance of a high consensus score. The themes of patient reported outcome measures and the impact of foot surgery on population health were reflected in 4 out of the 5 top research questions. These results are in agreement with both the published research priorities on Foot and Ankle Surgery and Foot Health by James Lind Alliance, which demonstrates the importance of further research in this topic. Interestingly, it was only the top research question that demonstrated similarity with the BOFAS priority setting project, while the remainder focused on rearfoot and ankle surgery. The podiatric surgery priorities tended to rank forefoot and midfoot surgeries as high priorities, which may be explained by the scope and focus of a single professional group.

These results have provided a consensus regarding the top ten research priorities and inform the podiatric surgery research strategy. These results must be considered in the light of the following limitations: resources and time only allowed for one stage of live voting. If there had been an opportunity for a second vote, higher consensus scores may have been achieved by removing lower ranked themes, topics, and questions. Another factor to consider is that bias may have been created by the unequal grouping of questions within each theme synthesised from the scoping survey: those with fewer questions are more likely to achieve greater consensus agreement scores. A disadvantage of targeting attendees of the podiatric surgery conference is that the opinions of other specialty groups (e.g., orthotists, physiotherapists, etc.) and patients could not be included.

This project did not receive any funding, and therefore was constrained by potential costs of organising and inviting patient groups, carers, and other specialities to the consensus study. The authors recognise the limitation that people and carers who have experienced foot surgery were not included in this study and this could have influenced the initial scoping survey, the subsequent rankings and ultimately the final priorities list. As this is the first research priority setting project within Podiatric Surgery, it was felt that completing the consensus voting live during the national conference would allow the greatest opportunity to discuss the importance of the project, in addition to engaging the greatest number of professionals. This approach limited patient involvement; however, the final agreement was not reliant on the completion and return of questionnaires which typically have a lower response rate [20].

This initial consensus will provide a foundation for research within podiatric surgery, on which the priorities and strategy can be refined at future events. Working groups to address each of the top five topics and questions are in progress. Collaboration with partners at higher education institutions who provide postgraduate podiatric surgery training has begun, with the aim of embedding a strong research culture within the training programme. Involvement with the Royal College of Podiatry Research Development and Innovation Committee has been integral to progressing this project, with a view to integrating into the overall research strategy of the Royal College of Podiatry. While the initial focus of research within podiatric surgery will aim to explore the top research questions and topics identified, questions which ranked highly but that did not place in the top 10 will be made available to undergraduate podiatry students and post graduate university students studying the Masters of Science in Podiatric Surgery. This will allow the research themes to be utilised with commencement of foundation studies and post graduate studies.