The Foot and Ankle Outcome Score (FAOS) During Early Recovery After Ankle Fracture

Comparison of four patient reported outcome measures in patients with ankle fracture: A study on patient preferences and psychometric properties

BACKGROUND

The aim was to assess psychometric properties of Manchester Oxford Foot Questionnaire (MOXFQ), the Self-reported Foot and Ankle Score (SEFAS), the Olerud Molander Ankle Score (OMAS), and the Forgotten Joint Score (FJS) in adults with ankle fractures.

METHODS

Patients received all four questionnaires 6, 12, 14, 24, 52, and 104 weeks following an ankle fracture. According to COSMIN guidelines, statistical tests were performed to assess floor- and ceiling effects, structural validity, construct validity and reliability. Cognitive interview was performed with 9 patients.

RESULTS

MOXFQ showed best model fit in Confirmatory Factor Analysis. When testing construct validity, all hypotheses were accepted except for OMAS and FJS. All questionnaires had an almost perfect test-retest reliability (Interclass Correlation Coefficient 0.81 to 0.91) and Cronbach's alpha ranged from 0.76 to 0.95. MOXFQ was the best rated questionnaire.

CONCLUSION

All questionnaires performed well and we recommend MOXFQ for future use in ankle fracture studies.

LEVEL OF EVIDENCE

Level IV.

Dislocations deteriorate postoperative functional outcomes in supination-external rotation ankle fractures

PURPOSE

To assess the relationship between dislocation and functional outcomes in supination-external rotation (SER) ankle fractures.

METHODS

A retrospective case series study was performed on patients with ankle fractures treated surgically at a large trauma center from January 2015 to December 2021. The inclusion criteria were young and middle-aged patients of 18-65 years with SER ankle fractures that can be classified by Lauge-Hansen classification and underwent surgery at our trauma center. Exclusion criteria were serious life-threatening diseases, open fractures, fractures delayed for more than 3 weeks, fracture sites ≥2, etc. Then patients were divided into dislocation and no-dislocation groups. Patient demographics, injury characteristics, surgery-related outcomes, and postoperative functional outcomes were collected and analyzed. The functional outcomes of SER ankle fractures were assessed postoperatively at 1-year face-to-face follow-up using the foot and ankle outcome score (FAOS) and American orthopedic foot and ankle society score and by 2 experienced orthopedic physicians. Relevant data were analyzed using SPSS version 22.0 by Chi-square or t-test.

RESULTS

During the study period, there were 371 ankle fractures. Among them, 190 (51.2%) were SER patterns with 69 (36.3%) combined with dislocations. Compared with the no-dislocation group, the dislocation group showed no statistically significant differences in gender, age composition, fracture type, preoperative complications with diabetes, smoking history, preoperative waiting time, operation time, and length of hospital stay (all p > 0.05), but a significantly higher Lauge-Hansen injury grade (p < 0.001) and syndesmotic screw fixation rate (p = 0.033). Moreover, the functional recovery was poorer, revealing a significantly lower FAOS in the sport/rec scale (p < 0.001). Subgroup analysis showed that among SER IV ankle fracture patients, FAOS was much lower in pain (p = 0.042) and sport/rec scales (p < 0.001) for those with dislocations. American orthopedic foot and ankle society score revealed no significant difference between dislocation and no-dislocation patients.

CONCLUSION

Dislocation in SER ankle fractures suggests more severe injury and negatively affects functional recovery, mainly manifested as more pain and poorer motor function, especially in SER IV ankle cases.

The minimal important change is not a universal fixed value across diagnoses when using the FAOS and FAAM in patients undergoing elective foot and ankle surgery

PURPOSE

This study aimed to calculate region and diagnosis-specific minimal important changes (MICs) of the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) in patients requiring foot and ankle surgery and to assess their variability across different foot and ankle diagnoses.

METHODS

The study used routinely collected data from patients undergoing elective foot and ankle surgery. Patients had been invited to complete the FAOS and FAAM preoperatively and at 3-6 months after surgery, along with two anchor questions encompassing change in pain and daily function. Patients were categorised according to region of pathology and subsequent diagnoses. MICs were calculated using predictive modelling (MICPRED) and receiver operating characteristic curve (MICROC) method and evaluated according to strict credibility criteria.

RESULTS

Substantial variability of the MICs between forefoot and ankle/hindfoot region was observed, as well as among specific foot and ankle diagnoses, with MICPRED and MICROC values ranging from 7.8 to 25.5 points and 9.4 to 27.8, respectively. Despite differences between MICROC and MICPRED estimates, both calculation methods exhibited largely consistent patterns of variation across subgroups, with forefoot conditions systematically showing smaller MICs than ankle/hindfoot conditions. Most MICs demonstrated high credibility; however, the majority of the MICs for the FAOS symptoms subscale and forefoot conditions exhibited insufficient or low credibility.

CONCLUSION

The MICs of the FAOS and FAAM vary across foot and ankle diagnoses in patients undergoing elective foot and ankle surgery and should not be used as a universal fixed value, but recognised as contextual parameters. This can help clinicians and researchers in more accurate interpretation of the FAOS and FAAM change scores.

LEVEL OF EVIDENCE

Level IV.

A Comprehensive Approach to PROMs in Elective Orthopedic Surgery: Comparing Effect Sizes across Patient Subgroups

Background: There is limited knowledge regarding the comparative patient-reported outcomes (PROMs) and effect sizes (ESs) across orthopedic elective surgery. Methods: All patient data between January 2020 and December 2022 were collected, and treatment outcomes assessed as a PROM difference between baseline and one-year follow-up. The cohort was divided into subgroups (hand, elbow, shoulder, spine, hip, knee, and foot/ankle). The PROM ESs were calculated for each patient separately, and patients with ES > 0.5 were considered responders. Results: In total, 7695 patients were operated on. The mean ES across all patient groups was 1.81 (SD 1.41), and the largest ES was observed in shoulder patients and the smallest in hand patients. Overall, shoulder, hip, and knee patients had a larger ES compared to hand, spine, and foot/ankle patients (p < 0.0001). The proportion of positive responders ranged between 91-94% in the knee, shoulder, and hip, and 69-70% in the hand, spine, and foot/ankle subgroups. Conclusions: The ESs are generally high throughout elective orthopedic surgery. However, based on our institutional observations, shoulder, hip, and knee patients experience larger treatment effects compared to hand, spine, and foot/ankle patients, among whom there are also more non-responders. The expected treatment outcomes should be clearly communicated to patients when considering elective surgery. Because of the study limitations, the results should be approached with some caution.

Preoperative temporary fixation for fractures around the ankle using a simple extensible external fixator significantly improves patient comfort

BACKGROUND

The authors developed a simple extensible external fixator, which has the advantages of easy application and inexpensiveness. The present study aimed to make a comparison between this external fixator and calcaneal traction in preoperative temporary fixation for malaligned ankle fractures and pilon fractures.

METHODS

From May 2020 to February 2022, patients with malaligned ankle fractures or Rüedi-Allgöwer type 2 or 3 pilon fractures with obvious soft tissue swelling were retrospectively reviewed and divided into the calcaneal traction group and the external fixation group. The two groups of patients were matched 1:1 before making comparisons.

RESULTS

A total of 38 patients were included. Higher General Comfort Questionnaire score and lower visual analog scale score were noticed in the external fixation group during hospitalization (p < 0.05), while the operation latency time, total cost, patient satisfaction, and functional outcomes one year after surgery were not significantly different between the two groups. No wound complications were observed.

CONCLUSION

Preoperative temporary fixation for fractures around the ankle using this simple extensible external fixator significantly improves patient comfort when compared to calcaneal traction.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Validation of anterior ankle soft tissue dynamics and shear modulus for anterior ankle impingement syndrome after ankle fracture surgery

Anterior ankle impingement syndrome (AAIS) has been reported to account for a high percentage of complications following ankle fracture surgery. The soft tissue etiology of AAIS is thought to be thickening and inflammation of the anterior ankle soft tissues intervening anteriorly at the tibiotalar joint, causing pain and functional limitation during dorsiflexion. However, the effects of anterior ankle soft tissue dynamics and stiffness on AAIS have yet to be clarified. This study aimed to determine the relationship between AAIS and the anterior ankle soft tissue thickness change ratio and shear modulus using ultrasonography (US). The participants were 20 patients with ankle joint fractures (AO classification A, B) who had undergone open reduction and internal fixation and 20 healthy adults. The evaluation periods were 3 months and 6 months postoperatively. US was used to delineate the tibialis anterior tendon, extensor hallucis longus tendon, and the extensor digitorum longus tendon over the talus and tibia on a long-axis image. Anterior ankle soft tissue thickness was measured as the shortest distance from the most convex part of the talus to the tendon directly above it. The Anterior ankle soft tissue thickness change ratio was determined by dividing the value at 0° dorsiflexion by the value at 10° plantarflexion. The same images as for the anterior soft tissue thickness measurement were drawn for the shear modulus measurement, and the average shear modulus (kPa) was calculated using shear-wave elastography. There was no significant difference in the thickness change ratio between the postoperative and healthy groups. Compared with the healthy group, the shear modulus was significantly higher at 3 and 6 months in the postoperative group (p < 0.01). The shear elastic modulus at 6-month postoperative group was significantly lower than at 3-month postoperative group (p < 0.01). Anterior ankle joint soft tissue stiffness may increase after surgery for an ankle fracture.

Injury severity at the time of sport-related ankle sprain is associated with symptoms and quality of life in young adults after 3-15 years

BACKGROUND

Ankle sprains are the most common sports-related injuries. Individuals with time-loss ankle sprains often experience residual symptoms and chronic ankle instability years after injury. Up to 90% of post-traumatic ankle osteoarthritis cases are associated with severe ankle sprain. This study aimed to examine whether ankle injury severity sustained during youth sports participation is associated with ankle symptoms and function.

MATERIALS AND METHODS

Cohort study included 50 young adults (mean age, 23 years) with a 3-to 15-year history of a youth-sport related 'significant ankle sprain' (SAS). The primary independent variable was injury severity, which was captured in the index SAS injury details through interviews. SAS was defined as ligament and other intra/extra-articular structure injuries that disrupted youth sport participation, at least 3 days of time loss, and required medical consultation. Severe SAS was defined as SAS involving >28 days of time loss, and non-severe SAS only involved ankle ligaments and/or with ≤28 days of time loss. The Foot and Ankle Outcome Score questionnaire was used to assess ankle symptoms and function. Descriptive statistics and multivariable linear regression models were used to examine the association between SAS severity and outcomes, with sex and time since injury as covariates.

RESULTS

Compared to participants with non-severe SAS, participants with a history of severe SAS demonstrated significantly poorer outcomes in symptoms [-18.4 (99% CI: -32.2 to -4.6)], pain [-10.1 (99% CI: -19.2 to -1.1)] and QoL [-17.1 (99% CI: -33.1 to -1.1)] in multivariable linear regression models.

CONCLUSIONS

Severe ankle sprain with a loss of > 4 weeks from sports participation at the time of injury is independently associated with poorer ankle symptoms, pain, and ankle-related quality of life after 3-15 years. Secondary prevention measures are needed in individuals with a history of severe ankle sprains to mitigate the potential health consequences.

Protocol for a randomised feasibility trial comparing a combined program of education and exercise versus general advice for ankle osteoarthritis

BACKGROUND

Ankle osteoarthritis (OA) is a serious problem with high associated pain and disability. While education and exercise are recommended for the initial management of OA, this has not been investigated in ankle OA. The primary aim of this study is to establish the feasibility of running a full-scale randomised controlled trial (RCT) investigating a combined education and exercise program compared to a general advice program for people with ankle OA. The secondary aims are to collect preliminary data which will inform sample size calculations, and understand the perspectives of people with ankle OA on their participation in the trial.

METHODS

Thirty individuals aged 35 years or older with symptomatic radiographic ankle OA will be recruited from the community and randomised to receive either a combined education and exercise program or a general advice program, both of which will be delivered by a physiotherapist in a group setting. Primary outcomes of feasibility include responses to study advertisements, number of eligible participants, recruitment rate, adherence with the intervention, fidelity of the intervention, adverse events, drop-out rate, and credibility and expectancy of the intervention. Secondary participant-reported outcomes will include global rating of change, patient acceptable symptom state, severity of ankle pain and stiffness, self-reported function, quality of life, satisfaction with treatment, and use of co-interventions. Follow up will be at 8 weeks and 3 months. Physical measures of 40 m walking speed, timed stairs descent, heel raise endurance and ankle dorsiflexion range of motion will be collected at baseline and 8 weeks. Primary feasibility outcomes will be reported descriptively, and estimates of the variability of secondary participant-reported and physical outcomes will be calculated. Semi-structured interviews will be conducted with participants to understand perspectives about the intervention and participation in the trial, with data analyzed thematically.

DISCUSSION

Study findings will establish the feasibility of running a full-scale RCT to investigate a combined education and exercise program compared to a general advice program for people with ankle OA. This study is a necessary first step to advance the international research agenda of evaluating the efficacy of exercise in the management of ankle OA.

TRIAL REGISTRATION

ACTRN12623000017628. Registered 10 January 2023, https://www.anzctr.org.au/ACTRN12623000017628.aspx .

Foot and Ankle Outcome Score (FAOS): Reference Values From a National Representative Sample

Background

The Foot and Ankle Outcome Score (FAOS) is widely used in clinical practice and research. However, FAOS reference values are missing to aid interpretation. This study aimed to establish national record-based reference values for the FAOS.

Methods

A national representative sample of 9996 adult Danish citizens was derived from the Danish Civil Registration System. The FAOS questionnaire was sent to all participants, including 2 supplemental questions regarding previous foot and ankle problems and body mass index (BMI). A threshold of 10 FAOS points was predefined as a clinically relevant difference across all 5 subscales.

Results

A total of 2759 participants completed the FAOS. Mean age of participants was 60.5 years, and 51% were women. The mean FAOS subscale scores were as follows: pain, 87.1 (95% CI 86.4-87.8); symptoms, 85.1 (95% CI 84.5-85.8); activity of daily living (ADL), 88.9 (95% CI 88.2-89.6); sport and recreation function 78.5 (95% CI 77.4-79.6); and quality of life (QOL), 79.9 (95% CI 79.0-80.9). The mean difference between men and women was small and not clinically relevant (ranged from 0.9 in ADL to 3.4 in QOL). The largest differences in mean scores between age groups ranged from 4.3 in symptoms to 16.4 in sport/rec. Except for the subscale sport/rec, all age-related differences were below the predefined threshold of 10 for clinical relevance. The difference in mean subscale scores between the lowest BMI group (<24.7) and the obese group (>30) ranged from 19.6 in ADL to 39.1 in sport/rec.

Conclusion

We found in our population that BMI severely impacted FAOS scores. We recommend using BMI-specific reference FAOS values. Separate FAOS reference values for men and women appear not needed. Stratifying reference values for age is likely not needed except for the subscale sport and recreation function.

Level of evidence

Level III, cohort study.

Spanish Translation, Cross-Cultural Adaptation, and Validation of the Olerud-Molander Ankle Score (OMAS) for Ankle Fractures

Background

The aim of this study was to translate and cross-culturally adapt the Olerud-Molander Ankle Score (OMAS) into Spanish and to assess its reliability and validity.

Methods

The translation and adaptation to develop the Spanish version of the OMAS (OMAS-Sp) was performed according to current international guidelines. The OMAS-Sp was administered to 98 patients with a surgically treated ankle fracture, and it was repeated 7-14 days later to assess construct reliability of each question's score and the total score. Test-retest reliability and the internal consistency were calculated, and concurrent validity was assessed by comparing the OMAS-Sp with the Foot and Ankle Outcome Score (FAOS). The presence of floor and ceiling effects was also analyzed.

Results

Adequate internal consistency was found with a Cronbach α of 0.821. Excellent test-retest reliability was demonstrated with an interclass correlation coefficient for the total score of 0.970 (95% CI 0.956-0.980; P < .001). Spearman correlation coefficients (r's) between the OMAS-Sp total score and the 5 FAOS subscales ranged from 0.944 to 0.951 (P < .001). No floor or ceiling effects were found.

Conclusion

The OMAS-Sp demonstrated adequate psychometric properties and is a valid and reliable tool for assessing outcomes in Spanish-speaking patients with surgically treated ankle fractures.

Level of Evidence

Level II, prospective cohort study.

Comparing the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability: Randomized controlled trial

OBJECTIVE

To compare the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability (CAI).

DESIGN

Two-arm, parallel-group, randomized, double-blind, controlled trial.

PARTICIPANTS

60 patients with unilateral CAI.

INTERVENTION

integral physiotherapy (n = 30) or conventional physiotherapy (n = 30).

OUTCOMES

Visual Analog Scale (VAS), dorsiflexion and plantarflexion range of motion, Star Excursion Balance Test (SEBT), Single Leg Hop (SLH) test, Foot and Ankle Outcome Score (FAOS), Lower Extremity Functional Score (LEFS), global rating of change, were gathered pre and post-intervention.

RESULTS

The ANOVA results revealed statistically significant interaction for FAOS, and LEFS outcome measures (P < 0.05) and the mean change results showed there were a favorable clinical difference incline toward the integral group (mean_integral = 20.14 (14.95-25.37), mean_Conventional = 29.46 (24.09-34.83)). There were no interactions between group and time among other outcome measures (P > 0.05). The group main effect did not show any statistical significance (P > 0.05).

CONCLUSION

Hip strengthening and balance exercises added to ankle rehabilitation could be more favorable on improving the patients' functional ability.

Short-Term Outcomes of Enhanced Recovery after Surgery (ERAS) for Ankle Fracture Patients: A Single-Center Retrospective Cohort Study

OBJECTIVE

Enhanced recovery after surgery (ERAS) has been successfully adopted for the improvement of medical quality and efficacy in many diseases, but the effect thereof for ankle fracture patients can vary. The aim of the present study was to explore the short-term postoperative outcomes of ERAS among ankle fracture patients.

METHODS

The present study was a retrospective cohort study conducted between January 2019 and May 2019. One hundred and sixty ankle fracture participations (58 males and 102 females, aged 41.71 ± 14.51 years) were included. The participants treated with open reduction and internal fixation were divided into two groups (non-ERAS vs. ERAS) depending on whether ERAS was applied. Postoperative outcomes included American Orthopedic Foot and Ankle Society (AOFAS) score, length of stay (LOS), hospital cost, complications, and consumption of opioids. To assess the association between the groups and outcomes, generalized estimating equation (GEE) modeling and multivariable linear regression analysis were performed.

RESULTS

The average follow-up periods of the participations were 24 months postoperatively. No significant differences were detected between the non-ERAS group and ERAS group with respect to the demographic of patients in terms of gender, age, Danis-Weber classification of fracture, dislocation of ankle joint, and comorbidity (P > 0.05). Significant differences in terms of a higher AOFAS score were found in the ERAS group compared with the non-ERAS group (6.73, 95% CI, 5.10-8.37, p < 0.001) at 3 months postoperatively (PO3M) and (4.73, 95% CI, 3.02-6.45, p < 0.001) at 6 months postoperatively (PO6M). However, similar AOFAS scores were found at 12 months postoperatively (PO12M) (0.28, 95% CI, -0.32 to 0.89, P > 0.05) and at 24 months postoperatively (PO24M) (0.56, 95% CI, -0.07 to 1.19, P > 0.05). Additionally, the GEE analysis and group-by-time interaction of AOFAS score revealed that the ERAS protocol could facilitate faster recovery for ankle fracture patients, with higher PO3M and PO6M (both P < 0.05). At the same time, significant differences in terms of a shorter length of stay (-3.19, 95% CI, -4.33 to -2.04, P < 0.01) and less hospital cost (-6501.81, 95% CI, -10955.21 to -2048.42, P < 0.01) were found in the ERAS group compared with the non-ERAS group.

CONCLUSION

By reducing LOS and hospital cost, the ERAS protocol might improve the medical quality and efficacy. The present study can provide a realistic evaluation and comparison of the ERAS protocol among ankle fracture patients, and ultimately guide clinical decision making.

Patient-reported outcomes after initial conservative fracture treatment in primary healthcare – a survey study

Background

Primary healthcare in Norway has first-line responsibility for medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care. However, some municipalities have X-ray facilities and handle minor fractures locally. We investigated patient-reported outcome measures after initial treatment of radiologically diagnosed fractures of the wrist, collarbone, and ankle at a primary healthcare centre in a rural municipality with a large ski resort. The patients’ general satisfaction with the treatment was also investigated.

Methods

Validated questionnaires were sent to patients with fractures of the wrist or collarbone (Quick DASH—Disability of Arm, Shoulder and Hand) or the ankle (FAOS -The Foot and Ankle Outcome Score). Patients with wrist and collarbone fractures also answered the Quality-of-life questions that are a subscale of the FAOS questionnaire for ankle fractures. Patient satisfaction was measured for all fracture groups. The Quick DASH scale ranges from 0 (no disability at all) to 100 (great disability), while for FAOS a score of 100 indicates no symptoms and 0 indicates extreme disabilities.

Results

A total of 148 of 238 patients answered the questionnaire (62% response rate). Patients with distal radius fractures had a mean Quick DASH score of 5.1 (median 0, range 0–77), and scores were significantly lower for males (p = 0.013) and increased with age (p = 0.024). Patients with collarbone fractures had a mean Quick DASH score of 2.1 (median 0, range 0–32) with no significant age or gender differences. Patients with ankle fractures had the following mean subscale-scores: Pain, 93.8; Symptoms, 71.4; Activities of daily living, 97.4; Sport, 90.0; and Quality of life, 92.1. The scores did not differ significantly by specialization of the physician. A total of 88% of the patients were highly or very highly satisfied with the handling of their fracture.

Conclusions

The patients reported low rates of functional disability and high rates of satisfaction after initial radiological diagnosis and treatment of their fracture at the primary healthcare centre. Specialisation of the treating physician was not associated with the outcome in any of the fracture types.