Validity and Reliability of Turkish Version of Olerud-Molander Ankle Score in Patients With Malleolar Fracture

Outcome measures after foot and ankle surgery: A Systematic Review

BACKGROUND

Research on outcomes measures after foot and ankle surgery is limited and methodological quality is not always assessed. We aimed to evaluate the measurement properties of patient-related outcome measures used in patients after foot- and ankle surgery.

METHODS

A Medline, Embase and Web of Sciences systematic review was performed including dates from 2000 up to April 2022. Inclusion criteria were foot and/or ankle surgery, described outcome(s) and it's assessed measurement properties. Methodological quality assessment was performed using the NOS-scale and the COSMIN-criteria.

RESULTS

143 studies (n = 18383) were included for final review, 82 about PROMs, 61 about clinical outcomes. A total of 23 different PROMs were evaluated, with a positive result in all measurement properties for the FAOS. There were positive results too for most measurement properties of the LEFS and the MOXFQ. Most clinical outcomes were radiological measures, with a high reliability for most measurements on plain radiographs and CT-scans.

CONCLUSIONS

To monitor foot and ankle outcome and evaluate treatment, we recommend the FAOS as the most suitable foot and ankle PROM.

LEVEL OF CLINICAL EVIDENCE

2.

Validity and reliability of the Manchester Oxford Foot Questionnaire (MOXFQ) in one-year postoperative ankle fracture patients-a validation study

BACKGROUND

Ankle fracture patients are a heterogenous group with differences in age, sex, fracture morphology, and treatment provided. With the increased focus on patient-centered treatment, patient-reported outcome measures (PROMs) are increasingly adopted by clinicians to facilitate best clinical practice. The Manchester Oxford Foot Questionnaire (MOXFQ) has demonstrated good measurement properties when used in patients with foot or ankle disease. The PROM has three domains: (1) Pain; (2) Walking/Standing; and (3) Social Interaction. One study found sufficient content validity for the Pain and Walking/Standing domains when used in the evaluation of ankle fracture patients. Another validation study demonstrated acceptable structural validity and reliability for the MOXFQ in ankle fracture patients 12 weeks after injury. The aim of this study is to assess the structural validity and reliability of the Norwegian version of the MOXFQ in the context of an ankle fracture patients one year after surgery and provide patient acceptable symptom state (PASS) estimates.

METHODS

A pragmatic cross-sectional study design was used to collect the one-year MOXFQ follow-up data from patients surgically treated for an ankle fracture in the period 2017 to 2020 at (Stavanger University Hospital). The structural validity and internal consistency were assessed using confirmatory factor analysis. A separate test-retest study including patients at least one year since ankle surgery was used in the assessment of reliability and measurement error.

RESULTS

A confirmatory factor analysis of the three-factor model of the MOXFQ had a good model fit (TLI 0.94; CFI 0.95; RMSEA 0.094; SRMR 0.039). However, the measurement model demonstrated poor discriminant validity of the three factors. A unidimensional model of the 16 items had worse model fit, while a second-order factor model demonstrated strong factor loadings for a second-order factor. A bi-factor model also revealed a strong general factor but also unique variance in the Pain and Social Interaction domain. The domains had good internal consistency (McDonald's omega 0.80 to 0.95) and test-retest reliability (ICC 0.80 to 0.92). The standard errors of measurements for the three domains were between 6.5 and 7.5, and 5.5 for the MOXFQ-Index (scale 0 to 100). PASS estimates for the (sub)scales were: Pain 45; Walking/Standing 39; Social Interaction 19; and MOXFQ-Index 34.

CONCLUSION

The MOXFQ with three domains demonstrated sufficient structural validity and reliability when used in the evaluation of a one-year postoperative ankle fracture population. Reporting the scores of the Pain and Walking/Standing domains was best supported.

Assessing Functional Ankle Instability in Sport: A Critical Review and Bibliometric Analysis

Functional Ankle Instability (FAI) is the subject of extensive research in sports and other environments. Given the importance of accurately measuring this latent construct, it is imperative to carry out a careful assessment of the available tools. In this context, the aim of this review was to take an in-depth look at the six most cited measurement tools to assess FAI, with a specific focus on patient-reported outcome measures related to ankle and foot. Four electronic databases (Web of Science, Scopus, Pubmed, and SportDiscus) were searched (up to November 2022) to identify the six most cited questionnaires for assessing FAI. Our analysis showed that the most cited questionnaires are the following: the Lower Extremity Functional Scale (LEFS), the Foot Function Index (FFI), the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the Olerud and Molander Ankle Score (OMAS), and the Cumberland Ankle Instability Tool (CAIT). Each questionnaire was thoroughly assessed and discussed in three sections: Development, Reliability, and Summaries. In addition, bibliometric data were calculated to analyze the relevance of each questionnaire. Despite variations in terms of validity and reliability, conceptualization, structure, and usefulness, the six questionnaires proved to be robust from a psychometric point of view, being widely supported in the literature. The bibliometric analyses suggested that the FAOS ranks first and the FFI ranks sixth in the weighted average of the impact factors of their original publications.

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.

Lateral Talar Subluxation Measurements in Nonoperatively Managed Weber B Ankle Fractures

Background

Lateral talar subluxation (LTS) was introduced as a measurement tool for evaluating isolated Weber B ankle fractures, with LTS >4 mm on gravity stress (GS) radiographs possibly indicating need for surgery. This study reviews LTS measurements in nonoperatively managed isolated Weber B fibula fractures to further investigate the validity of this previously stated cutoff.

Methods

The senior authors previously reported outcomes of a novel algorithm for nonoperative management of isolated Weber B ankle fractures. Outcome scores reported include American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for activities of daily living (FAAM/ADL), and visual analog scale (VAS) scores. All patients achieved union of their fracture. LTS was measured on GS radiographs of both injured and contralateral uninjured extremities.

Results

Forty-two patients were included with minimum 1-year follow-up. Average age was 49 years (range 19-72). Mean measurements on injury GS radiographs were as follows: medial clear space (MCS) 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0-4.7 mm), with 35 (83.3%) patients having injury LTS ≤4 mm. Mean measurements on contralateral (uninjured) GS radiographs were as follows: MCS 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0-4.8 mm). There was no statistically significant difference in all outcome measures based on amount of LTS (<2 mm, 2-4 mm, >4 mm).

Conclusion

Most patients had injury LTS ≤4 mm, although those with LTS >4 mm had excellent outcome scores. LTS measurements on normal ankles reveal a large range. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but the 4-mm cutoff may not be entirely reliable. Further studies are required to validate LTS as a decision-making tool.

Level of Evidence

Level IV, case series.

Ankle fractures: a systematic review of patient-reported outcome measures and their measurement properties

PURPOSE

Ankle fractures are commonly occurring fractures, especially in the aging population, where they often present as fragility fractures. The disease burden and economic costs to the patient and society are considerable. Choosing accurate outcome measures for the evaluation of the management of ankle fractures in clinical trials facilitates better decision-making. This systematic review assesses the evidence for the measurement properties of patient-reported outcome measures (PROMs) used in the evaluation of adult patients with ankle fractures.

METHODS

Searches were performed in CINAHL, EMBASE, Medline and Google Scholar from the date of inception to July 2021. Studies that assessed the measurement properties of a PROM in an adult ankle fracture population were included. The included studies were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of PROMs.

RESULTS

In total, 13 different PROMs were identified in the 23 included articles. Only the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM) presented some evidence on content validity. The Olerud-Molander Ankle Score (OMAS) and Self-reported Foot and Ankle Score (SEFAS) displayed good evidence of construct validity and internal consistency. The measurement properties of the OMAS, LEFS and SEFAS were most studied.

CONCLUSION

The absence of validation studies covering all measurement properties of PROMs used in the adult ankle fracture population precludes the recommendation of a specific PROM to be used in the evaluation of this population. Further research should focus on validation of the content validity of the instruments used in patients with ankle fractures.

The minimal clinically important difference (MCID) of the Olerud Molander Ankle Score (OMAS) in patients with unstable ankle fracture

INTRODUCTION

The Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury.

MATERIALS AND METHODS

Data for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC).

RESULTS

This cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4-20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1-15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months.

CONCLUSIONS

The calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3-6-month follow-up and from 7.5 to 11.4 at 6-12-month follow-up, depending on moment and method.

An evaluation of the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture

OBJECTIVES

The aim of this study is to evaluate the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture.

METHODS

Patients completed outcome measure questionnaires at baseline, six, 10- and 16-weeks postinjury as part of an ongoing clinical trial on ankle fracture rehabilitation. The internal consistency, convergent validity, structural validity and interpretability of the Olerud Molander Ankle Score was assessed. This was achieved through using the respective analysis methods of Cronbach's alpha, correlation coefficients, principal component analysis, evaluation of floor and ceiling scores and estimation of the minimally important change using anchor-based methods.

RESULTS

The Olerud Molander Ankle Score showed adequate convergent validity against hypotheses set in relation to scores of comparator instruments. Principal component analysis demonstrated that the measure has two subscales: ankle function and ankle symptoms. The internal consistency of the measure and the ankle function subscale was sufficient, but inconclusive for the ankle symptoms subscale. There were no floor and ceiling effects present within the scores and the estimated minimally important change was 9.7 points.

CONCLUSION

The Olerud Molander Ankle Score demonstrates sufficient measurement properties and is likely to be primarily measuring the construct of patient reported function following ankle fracture. Further research should evaluate the relevance of other domains to individuals recovering from and ankle fracture, such as social participation and psychological wellbeing. The development of a core outcome set would be advantageous to standardise outcome measurement collection in this area.

American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language

We evaluated the reliability and validity of the Persian translation of the American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal joint scale (AOFAS Hallux MTP-IP). The translated AOFAS Hallux MTP-IP scale form was completed for 101 patients with hallux deformities; the subjective questions were answered by the patients, whereas the orthopedic foot and ankle surgeon and his assistant answered the objective questions. The validated Persian version of the 36-Item Short Form Survey Instrument (SF-36) was used for validity assessment. Eighty-five females and 16 males with a mean age of 49 years were enrolled. Hallux valgus and hallux rigidus was the diagnosis in 73 and 28 patients, respectively. Intrarater reliability had a high level of correlation (rho >0.6) for all subscales and total score. Although the correlation between the total score of the AOFAS Hallux MTP-IP scale and role: physical subscale of SF-36 was the highest (rho = 0.47), the total score of AOFAS Hallux MTP-IP scale and the other 7 domains of SF-36 had a correlation ranging between -0.17 and 0.43. Moreover, the correlation between total score of AOFAS-Hallux MTP-IP and SF-36 physical component summary scale was 0.50, which was higher than the correlation between total score of AOFAS and SF-36 mental component summary scale (rho = 0.35). Convergent validity was approved for MTP joint motion (0.59), IP joint motion (0.51), and callus (0.56) items of AOFAS-Hallux MTP-IP. Spearman's rank correlation coefficient between all items of the functional subscale of AOFAS Hallux MTP-IP scale with its own subscales was higher than the coefficient between these items and other subscales, including pain and alignment (discriminate validity). Floor and ceiling effects were calculated as 2% and 1%, respectively. Our findings indicate that the translated Persian version of the AOFAS Hallux MTP-IP scale is a reliable instrument, but its validity is not satisfactory.

A systematic review of the measurement properties of patient reported outcome measures used for adults with an ankle fracture

BACKGROUND

Ankle fractures are painful and debilitating injuries that pose a significant burden to society and healthcare systems. Patient reported outcome measures (PROMs) are commonly used outcome measures in clinical trials of interventions for ankle fracture but there is little evidence on their validity and reliability. This systematic review aims to identify and appraise evidence for the measurement properties of ankle specific PROMs used in adults with an ankle fracture using Consensus Based Standards for the Selection of Health Measurement Instrument (COSMIN) methodology.

METHODS

We searched MEDLINE, Embase and CINAHL online databases for evidence of measurement properties of ankle specific PROMs. Articles were included if they assessed or described the development of the PROM in adults with ankle fracture. Articles were ineligible if they used the PROM to assess the measurement properties of another instrument. Abstracts without full articles and conference proceedings were ineligible, as were articles that adapted the PROM under evaluation without any formal justification of the changes as part of a cross-cultural validation or translation process. Two reviewers completed the screening. To assess methodological quality we used COSMIN risk of bias checklist and summarised evidence using COSMIN quality criteria and a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Two reviewers assessed the methodological quality and extracted the data for a sample of articles.

RESULTS

The searches returned a total of 377 articles. From these, six articles were included after application of eligibility criteria. These articles evaluated three PROMs: A-FORM, OMAS and AAOS. The A-FORM had evidence of a robust development process within the patient population, however lacks post-formulation testing. The OMAS showed sufficient levels of reliability, internal consistency and construct validity. The AAOS showed low quality evidence of sufficient construct validity.

CONCLUSIONS

There is insufficient evidence to support the recommendation of a particular PROM for use in adult ankle fracture research based on COSMIN methodology. Further validation of these outcome measures is required in order to ensure PROMs used in this area are sufficiently valid and reliable to assess treatment effects. This would enable high quality, evidenced-based management of adults with ankle fracture.

Primary outcome measures used in interventional trials for ankle fractures: a systematic review

Background

Ankle fractures cause considerable pain, loss of function and healthcare resource use. High quality randomised controlled trials are required to evaluate the optimal management protocols for ankle fracture. However, there is debate regarding the most appropriate outcome measure to use when assessing patients with ankle fractures. The aim of this systematic review is to identify and summarise primary outcome measure use in clinical trials of non-pharmacological interventions for adults with an ankle fracture.

Methods

We performed comprehensive searches of the Medline, Embase, CINAHL, AMED and Cochrane CENTRAL databases, as well as ISRCTN and ClinicalTrials.gov online clinical trial registries on 19/06/2019 with no date limits applied. The titles and abstracts were initially screened to identify randomised or quasi-randomised clinical trials of non-pharmacological interventions for ankle fracture in adults. Two authors independently screened the full text of any articles which could potentially be eligible. Descriptive statistics we used to summarise the outcome measures collected in these articles including an assessment of trends over time. Secondary analysis included a descriptive summary of the multi-item patient reported outcome measures used in this study type.

Results

The searches returned a total of 3380 records. Following application of the eligibility criteria, 121 records were eligible for inclusion in this review. The most frequently collected primary outcome measures in this type of publication was the Olerud Molander Ankle Score, followed by radiographic and range of movement assessments. There was a total of 28 different outcome measures collected and five different multi-item, patient reported outcome measures collected as the primary outcome measure. There was a sequential increase in the number of this type of study published per decade since the 1980’s.

Conclusion

This review demonstrates the wide range of measurement methods used to assess outcome in adults with an ankle fracture. Future research should focus on establishing the validity and reliability of the outcome measures used in this patient population. Formulation of a consensus based core outcome set for adults with an ankle fracture would be advantageous for ensuring homogeneity across studies in order to meta-analyse trial results.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2770-2) contains supplementary material, which is available to authorized users.

Two-Stage Surgery for the Malleolar Fracture-Dislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results

Soft tissue injuries associated with malleolar fracture-dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture-dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot-ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p = .007), waiting time from admission to surgery (p < .001), gender (p = .005), and Tscherne soft tissue injury scores (p < .001). The mean AOFAS hindfoot-ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p = .094 and p = .126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture-dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot-ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period.