EFAS Score —Validation of Persian Version by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in nine European languages (English, German, French, Italian, Polish, Dutch, Swedish, Finnish, Turkish). From other languages under validation, the Persian version finished data acquisition and underwent further validation.MethodsThe Persian version of the EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Persian version (completed during initial validation study in nine other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory.ResultsThe internal consistency was confirmed in the Persian version (Cronbach’s Alpha 0.82). The Standard Error of Measurement (SEM) was 0.38 and is similar to other language versions. Between baseline and follow-up, 97% of patients showed an improvement on their EFAS score, with excellent responsiveness (effect size 1.93).ConclusionsThe Persian EFAS Score version was successfully validated in patients with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.     

EFAS Score - Validation of Portuguese Version by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in ten languages (English, German, French, Italian, Polish, Dutch, Swedish, Finnish, Turkish, Portuguese). From other languages under validation, the Portuguese version completed data acquisition and underwent further validation.MethodsThe Portuguese version of the EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Portuguese version (completed during initial validation study in nine other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory.ResultsThe internal consistency was confirmed in the Portuguese version (Cronbach’s Alpha 0.84). The Standard Error of Measurement (SEM) was 0.27 and is similar to other language versions. Between baseline and follow-up, 69.4% of patients showed an improvement on their EFAS score, with adequate responsiveness (effect size 0.64).ConclusionsThe Portuguese EFAS Score version was successfully validated in patients with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.net.     

Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery

BackgroundPatient-reported outcomes (PROs) are widely accepted measures for evaluating outcomes of surgical interventions. As patient-reported information is stored in electronic health records, it is essential that there are valid electronic PRO (ePRO) instruments available for clinicians and researchers. The aim of this study was to evaluate the validity of electronic versions of five widely used foot and ankle specific PRO instruments.MethodsAltogether 111 consecutive elective foot/ankle surgery patients were invited face-to-face to participate in this study. Patients completed electronic versions of the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the modified Lower Extremity Function Scale (LEFS), the Manchester–Oxford Foot Questionnaire (MOXFQ), and the Visual Analogue Scale Foot and Ankle (VAS-FA) on the day of elective foot and/or ankle surgery. Construct validity, coverage, and targeting of the scales were assessed.ResultsBased on general and predefined thresholds, construct validity, coverage, and targeting of the ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA were acceptable. Major issues arose with score distribution and convergent validity of the modified LEFS instrument.ConclusionsThe ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA provide valid scores for foot and ankle patients. However, our findings do not support the use of the modified LEFS as an electronic outcome measure for patients with orthopedic foot and/or ankle pathologies.     

EFAS Score—Validation of Spanish and Estonian Versions by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in 11 languages (Dutch, English, German, Finnish, French, Italian, Polish, Portuguese, Persian, Swedish, Turkish). From other languages under validation, the Spanish and Estonian versions completed data acquisition and underwent further validation.MethodsThe EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during the initial validation study), 2) item reduction and scale exploration (completed during the initial validation study), 3) confirmatory analyses and responsiveness of the Spanish and Estonian versions (completed during the initial validation study in seven other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory.ResultsThe internal consistency of the scale was confirmed in the Spanish and Estonian versions (Cronbach’s Alpha>0.8). Responsiveness was good, with moderate to large effect sizes in both languages, and evidence of a statistically significant positive association between the EFAS Score and patient-reported improvement.ConclusionsThe Spanish and Estonian EFAS Score versions were successfully validated in orthopaedic ankle and foot surgery patients, with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.net.     

Practical aspects of foot and ankle arthroscopy

Arthroscopy of the foot and ankle, although sometimes technically challenging, is a useful tool for the foot and ankle surgeon. Burman in 1931 was the first to attempt arthoscopy of the ankle joint and surmised that it was not a suitable joint for arthroscopy because of its narrow intra-articular space. With the development of smaller-diameter arthroscopes and improvements in joint distraction techniques, Watanabe was the first to present a series of 28 ankle arthroscopes in 1972. At present, arthroscopy is used not only to evaluate and treat intra-articular abnormalities but also for endoscopic and tendoscopic procedures.     

The Dutch version of the Oxford Ankle and Foot Questionnaire for Children: Useful for evaluation of pediatric foot problems in groups

Background

The purpose of this study is to develop a Dutch version of the Oxford Ankle and Foot Questionnaire for Children (OxAFQ-c) to allow evaluation of pediatric foot care.

Reliability,validity and clinical applicability of the German version of the European Foot and Ankle Society Score

BackgroundPurpose of this study was an external evaluation of the recently developed European Foot and Ankle Society (EFAS) Score.MethodsFrom July 2021 to January 2022, all consecutive patients with foot and ankle disorders were asked to complete three validated questionnaires prior to the medical examination. Validity was evaluated with correlations between the EFAS Score, Manchester-Oxford Foot Questionnaire (MOxFQ) and Foot and Ankle Outcome Score (FAOS). Cronbach’s alpha, floor and ceiling effects and the minimal important difference (MID) were determined.ResultsIn a total of 161 included patients, the EFAS Score demonstrated a very good correlation with the MOxFQ index score (r = 0.76, p < 0.001). There were no floor or ceiling effects. Cronbach’s alpha was 0.863, and the MID amounts 3 points and 7 points for significant changes respectively.ConclusionIn terms of reliability and validity, the EFAS Score demonstrated good to excellent psychometric values.A change of 7 points or more in the EFAS Score in longitudinal examinations is clinically highly relevant.     

Evaluation of the validity of the Foot Function Index in measuring outcomes in patients with foot and ankle disorders

BACKGROUND: There is uncertainty regarding which outcomes tools should be used to report the results of treatment for patients with foot and ankle disorders. This study evaluates the validity of the Foot Function Index (FFI) by examining its level of correlation to the Medical Outcomes Study Short Form-36 (SF-36). The SF-36 is an extensively validated outcomes tool that has been used as a benchmark in examining the validity of several orthopaedic outcomes tools. METHODS: Seventy-three patients were recruited at a tertiary referral foot and ankle practice. Patients completed packets which included informed consent forms, the FFI, and the SF-36 questionnaires. The questionnaires were scored and Pearson correlation coefficients were determined between the three domains of the FFI and the eight SF-36 sub-scales, as well as the two SF-36 summary scales. RESULTS: Sixty-nine patients completed an adequate number of items to be included in the study. The mean age of the patient sample was 46 (range 16 to 82) years and 44 were women (64%). Twenty-one patients (30%) had conditions affecting the forefoot, while 48 patients (70%) had conditions affecting the ankle or hindfoot. All three FFI domains had moderate to high levels of correlation to many of the SF-36 scales. The Disability domain of the FFI had the most consistent level of correlation to the SF-36 with Pearson coefficients in the range of -0.23 to -0.69. The Activity Limitation (r=-0.28 to -0.64) and Pain domains (r=-0.10 to -0.61) also demonstrated moderate levels of correlation to several of the SF-36 scales. CONCLUSIONS: The consistently moderate to high levels of correlation of the FFI to the SF-36 seen in this study support the FFI as a valid measure of health status. This suggests that the FFI is a reasonable method to monitor patient outcomes. Future studies should focus on determining if the FFI improves responsiveness to clinical change when used in combination with generic instruments like the SF-36.     

The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis

IntroductionRheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases.AimThis paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy.Main findingsThe majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3–5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery.ConclusionGood communication is needed between the surgical team and the local Rheumatology department managing the patient’s disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.     

Dance medicine of the foot and ankle: a review

All forms of dance are highly demanding activities, with a lifetime injury incidence of up to 90%. Most dance types are stressful, particularly on the dancer's forefoot, but certainly there is no area of the foot or ankle that is exempt from potential injury. Dancers often have unusual difficulties related to the dynamic biomechanical forces required by their individual dance form. A thorough understanding of these movements guides the physician to the cause of the injury, particularly in understanding specific overuse injuries. This article discusses biomechanics of the foot and the imaging and treatment of dance-related injuries.     

腓动脉穿支蒂螺旋桨皮瓣修复足踝部软组织缺损

目的 :探讨腓动脉穿支蒂螺旋桨皮瓣修复足踝部软组织缺损的临床疗效。方法:自2012年6月至2014年4月,采用腓动脉穿支蒂螺旋桨皮瓣治疗足踝部软组织缺损患者20例,其中男14例,女6例;年龄8~64岁,平均(36.2±4.6)岁;缺损面积5 cm×2 cm~22 cm×7 cm。损伤至手术时间8~90 d,平均(38.2±6.2)d。末次随访时采用美国足踝外科学会(AOFAS)踝-后足评分进行临床疗效评价。结果:20例均获随访,时间6~24个月,平均(13.5±2.2)个月。皮瓣外观及质地良好。手术时间90~210 min,平均(120±32)min。19例皮瓣全部存活,1例出现皮瓣部分坏死予再次清创植皮术后治愈。末次随访时AOFAS评分为(93.1±10.0),其中优14例,良6例。结论:腓动脉穿支蒂螺旋桨皮瓣治疗足踝部软组织缺损安全有效,临床疗效满意。     

Foot and ankle fractures at the supination line

Background

The supination line is a fictive line along the foot and ankle, on which over twenty fracture types and approximately ten different ligamentous sprain-injuries have been identified.

Objective

The current study was conducted to evaluate the incidence of different types of supination line injuries visible at the initial radiographs at the Emergency Department and to determine the type and percentage of misdiagnosed injuries.

Method

Retrospective study of consecutive patients who visited the Emergency Department, between January 1 and June 30, 2009, after sustaining an injury of the foot or ankle and had a radiograph taken within 24 h of the incident.

Results

In the 6-month study period 1284 patients were included. In these cases the trauma mechanism was a sprain in 780 patients (60.7%). Of these patients 310 suffered from a fracture (40%). There were 36 (4.6%) false-positive cases and in 91 (11.7%) cases the initial diagnosis was false-negative. The number with a missed fracture expressed as a percentage of all patients with a fracture was 29.4% (91/310).

Conclusion

Detection of injuries along the supination line remains difficult. This study might aid in decreasing the number of misdiagnosed injuries, which is of value as these might negatively affect outcome.     

Implications of obesity in patients with foot and ankle pathology

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m². It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.     

Bone mass and anthropometry in patients with osteoarthritis of the foot and ankle

BackgroundPatients with hip and knee osteoarthritis (OA) have high bone mineral density (BMD) and high BMI. If the same accounts for patients with foot or ankle OA is unknown.MethodsWe measured BMD and femoral neck (FN) width by dual-energy X-ray absorptiometry in 42 women and 19 men with idiopathic OA in the foot or ankle, and in 99 women and 82 men as controls.ResultsWomen with OA had significant higher BMI than controls. Women with OA had higher BMI-adjusted BMD (p < 0.01) and smaller BMI-adjusted FN width (p < 0.01) than controls. Men with OA had higher BMI adjusted-BMD (p < 0.05) and smaller BMI-adjusted FN width (p < 0.01) than controls.ConclusionPatients with OA in the foot or ankle have higher BMD and smaller bone size than being expected by their BMI. This phenotype may provide unfavourable forces across the joint and is hypothetically important for development of OA.     

The forgotten foot – An assessment of foot and ankle radiograph pathology in final year medical students

IntroductionIt has been shown that doctors in Emergency Departments (EDs) have inconsistent knowledge of musculoskeletal anatomy. This is most likely due to a deficiency in focused musculoskeletal modules at undergraduate level in medical school. The aims of this study were to evaluate the knowledge of final year medical students on foot anatomy and common foot and ankle pathology as seen on radiographs.MethodsFinal year medical students were asked to complete our short examination on a handout. The handout was anonymous and non-mandatory. There were four images. The first image is the anatomical section and the remaining images are the pathological section.ResultsAll 235 students responded. 57% were females. For the identification of the normal bones of the foot as shown on an X-ray, the average score for the group was 2.69 (out of a maximum of 6) {SD 1.67}7. Only 8.3% achieved a 6/6 or 100% grade i.e. recognising all six bones correctly. A further 8.3% achieved 5/6 (83%). 8.3% failed to correctly identify any bone seen on the X-ray, a corresponding score of 0.DiscussionThis quick test showed normal anatomy of the foot and common pathology. One would expect final year medical students to be familiar with, especially two weeks before their finals in surgery. The curriculum should address the paucity of time spent in educating students in foot and ankle pathology.     

足踝损伤的分类与治疗的要点和难点

足踝部损伤主要有踝关节骨折脱位、距骨骨折脱位、跟骨骨折以及跖骨骨折、趾骨骨折、跖趾关节脱位、踝关节周围软组织损伤等。足踝损伤防治的重点是踝关节骨折脱位、距骨骨折脱位、跟骨骨折以及踝关节周围软组织损伤。本文针对足踝损伤的要点和难点分类进行阐述。1踝关节骨折目前踝关节骨折的分类主要有:Ashhurst分类法[1]、Lauge-Hanson分类法[2]、Danis-Weber分类法[3]。Ashhurst分类法按照外力的性质分类,然后按单踝、双踝、三踝骨折分级,优点是简单易记,对认识外力的性质很有帮助,缺点是没有考虑到外伤时的体位、姿势等复合因素;Laug…     

Physical therapy and rehabilitation of the foot and ankle in the athlete

Foot and ankle injuries in athletes are common. Physical therapy plays a fundamental role in the management of sports injuries. The purpose of this article is to (1) raise awareness for using physical therapy for treatment of foot and ankle injuries in athletes, (2) discuss considerations specific to athletes during the rehabilitation process, and (3) increase the reader's knowledge about the in-depth role of physical therapy in the management of foot and ankle injuries in athletes.     

Effects of teriparatide on fusion rates in patients undergoing complex foot and ankle arthrodesis

BackgroundHere, we determined whether teriparatide treatment would increase fusion rates after foot and ankle arthrodesis by comparing treatment results between patients with high-risk factors for nonunion who received teriparatide against those who did not.MethodsWe retrospectively reviewed 66 consecutive patients who underwent foot and ankle arthrodesis. The inclusion criterion was the presence of at least one of the following risk factors for nonunion after previous foot and ankle arthrodesis: deformity, bone defects, avascular necrosis, and nonunion. Sixteen patients were finally enrolled and divided into 2 groups: 8 patients received teriparatide treatment after fusion surgery (PTH group), and 8 patients did not (control group).ResultsThe fusion rate was significantly greater in the PTH group than in the control group (100% vs 50%). Four patients in the control group developed nonunion, 3 of whom underwent revision fusion; however, all patients received the teriparatide treatment after revision surgery and subsequently achieved union. No significant differences in demographics, fusion sites, and complication rates were found.ConclusionThough the sample size was small, the current study suggests that teriparatide administration may improve fusion rates in patients with high-risk factors for nonunion after foot and ankle arthrodesis.     

Foot and ankle tuberculosis: Case series and literature review

Foot and ankle tuberculosis (TB) is a rare presentation of skeletal TB. The uncommon site along with low index of clinical suspicion in the western world leads to delays in the diagnosis and treatment. This can make joint sparing procedures less successful, especially in the midfoot where the joints can often be interconnected. Plain radiographs have low sensitivity and specificity and cross sectional imaging in the form of MRI or CT is more reliable. Treatment involves the use of multiple anti-tuberculous drugs in the first instance, followed by surgery to address any symptomatic deformity and/or secondary degenerative changes. We present our experience on the management of this rare problem and review the literature on the clinical presentation, diagnosis, imaging modalities and treatment.