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

BACKGROUND: The Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in 13 languages. Currently, the Danish version completed data acquisition and underwent further validation. METHODS: 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. RESULTS: The internal consistency was confirmed in the Danish version (Cronbach's Alpha 0.88). The Standard Error of Measurement (SEM) was 0.31 and is similar to other language versions. Between baseline and follow-up, 77.2% of patients showed an improvement on their EFAS score, with adequate responsiveness (effect size 1.05). CONCLUSIONS: The Danish 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.

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

BACKGROUND: The 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. METHODS: The 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. RESULTS: The 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. CONCLUSIONS: The 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.

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

BACKGROUND: The 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. METHODS: The 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. RESULTS: The 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). CONCLUSIONS: The 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.

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

BACKGROUND: The 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. METHODS: The 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. RESULTS: The 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). CONCLUSIONS: The 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 Finnish and Turkish versions by the Score Committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: The Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in seven European languages (English, German, French, Italian, Polish, Dutch, Swedish). From other languages under validation, the Finnish and Turkish versions finished data acquisition and underwent further validation. METHODS: 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 Finnish and Turkish version (completed during 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. RESULTS: The internal consistency of the scale was confirmed in the Finnish and Turkish 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. CONCLUSIONS: The Finnish and Turkish EFAS Score versions were successfully validated in the orthopaedic ankle and foot surgery patients, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

EFAS Score - Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages. METHODS: The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and 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 analyses from classical test theory and item response theory. RESULTS: Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed. CONCLUSIONS: The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction - Results from a multi-centre study.

BACKGROUND: Charcot osteo-neuroarthropathy (CN) of the foot can induce severe instability and deformity. Results of a consecutive clinical multi-centre study with Midfoot Fusion Bolt (MFB, Synthes GmbH, Oberdorf, Switzerland) are reported. METHODS: All patients (aged 18 years and older) treated between 2009 and 2013 with surgical reconstruction of the midfoot with MFB for CN were included. Demographics, pre-surgical health status, details of foot pathology, details of surgery, postoperative treatment, treatment failure, and adverse events were registered. The following radiographic angles were measured on pre-op, post-op and last follow-up radiographs: talo-1st metatarsal (TMT) angle dorsoplantar and lateral view, and calcaneo-5th metatarsal angle. RESULTS: Forty-seven patients (48 feet) were included in three centres. In 38 patients (80.1%) diabetes was diagnosed. Wound healing problems occurred in 21% of patients and recurrent ulceration in 13%. Revision surgery for loss of correction was performed in three cases (6%). Union rate at final follow-up was 98%. Major amputation for deep infection was performed in two patients (4%), minor amputation at the foot level in three cases (6%). Failure was more frequent when only one MFB (instead of 2 or 3) was used and no Gastrocnemius lengthening was performed. Radiographic alignment significantly improved pre- versus postoperatively and preoperatively versus follow-up. CONCLUSIONS: Realignment and fixation with MFB in severe CN result in adequate correction with minimal loss of correction in the observed clinical course. The non-union rate was lower than previously reported. Stable fixation with MFB is a valuable treatment option for CN with minimal loss of correction and high union rates. The use of a minimum of two bolts is recommended to avoid recurrent deformity. Clinical Trials.gov: NCT01770639.

Post-traumatic in situ fusion after calcaneal fractures: a retrospective study with 7-28 years follow-up.

BACKGROUND: In situ fusion as salvage operation after calcaneal fractures has been used. In this retrospective investigation, a group of in situ fused patients is analyzed with long-term follow-up. METHODS: Twenty-nine patients with in situ single or multiple fusions performed between 1970 and 1990 were included. In 1998 these patients were examined with plain radiographs and computerized tomography (CT) scan of the affected foot. Also, a visual analogue score (VAS) for calcaneal fractures, short form health survey (SF-36), Olerud Molander score and American Orthopaedic Foot and Ankle society (AOFAS) hindfoot score were evaluated. RESULTS: The plain radiographs and CT scan showed severe remaining deformities in these patients. The outcome parameters were generally poor and correlated to the degree of remaining deformity. CONCLUSIONS: Simple in situ fusion, without consideration of the deformity at hand, after a calcaneal fracture is not an adequate treatment and generally associated with poor outcome.

Factors affecting long-term treatment results of displaced intraarticular calcaneal fractures: a post hoc analysis of a prospective, randomized, controlled multicenter trial.

OBJECTIVES: To study the factors affecting long-term treatment results of displaced intraarticular calcaneal fractures (DIACFs). DESIGN: A post hoc analysis. SETTINGS: Tertiary care teaching hospitals. PATIENTS: Eight to twelve years of results from a randomized controlled multicenter trial of operative versus nonoperative treatment (n = 56) were divided into 2 groups: the superior 50% results (n = 28) and the inferior 50% results (n = 28), regardless of the treatment given. The determinant of this division was a visual analog score for pain and function. INTERVENTIONS: The operative treatment consists of open reduction and internal fixation, whereas the nonoperative treatment consists of nonweight bearing and early range of motion exercise. MAIN OUTCOME MEASUREMENTS: A visual analog score for pain and function, the short-form 36 (SF-36) general health outcome questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Olerud-Molander score. We compared age, sex, fracture type (Sanders classification), treatment given, Böhler angle, residual articular surface step-off at healing, type of occupation, and injury insurance between the 2 groups. RESULTS: Patients of the superior group had higher physical SF-36, AOFAS, and Olerud-Molander score than in the inferior group. Operative treatment, better Böhler angle and articular surface restoration, light labor/retirement, and absence of injury insurance were more common in the superior group. Age, sex, pretreatment Böhler angle, and fracture type were comparable in the superior and inferior groups. CONCLUSIONS: The decision making for definitive treatment of intraarticular calcaneal fractures is multifactorial with a spectrum of results and trends such as patient demographic features that should be considered in choosing the best treatment option. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial.

BACKGROUND: We conducted a prospective, randomized, controlled multicenter trial to compare operative with nonoperative treatment of displaced intra-articular calcaneal fractures. METHODS: Eighty-two patients who presented to five trauma centers from 1994 to 1998 with an intra-articular calcaneal fracture with ≥2 mm of displacement (as verified by computed tomography) were randomized to operative or nonoperative treatment. Independent observers followed the two groups radiographically and clinically at one year and eight to twelve years. The primary outcome measures were a visual analog scale (VAS) for pain and function and the self-administrated Short Form (SF)-36 general health outcome questionnaire. The secondary outcome measures were residual pain evaluated with a VAS, the American Orthopaedic Foot & Ankle Society (AOFAS) scale, and the Olerud-Molander (OM) scale. RESULTS: Forty-two patients in the operative treatment group and forty in the nonoperative group were included. The two groups were comparable with respect to age, sex, and fracture types. Seventy-six patients were available for follow-up at one year and fifty-eight at eight to twelve years. The primary and secondary outcome measures did not differ significantly between the two treatment groups at one year of follow-up. At eight to twelve years of follow-up, there was a trend toward better scores on the patient-reported primary VAS score for pain and function (p = 0.07) and the physical component of the SF-36 (p = 0.06) in the operative group. The prevalence of radiographically evident posttraumatic subtalar arthritis was lower in the operative group (risk reduction, 41%). CONCLUSIONS: Operative treatment was not superior in managing displaced intra-articular calcaneal fractures at one year of follow-up but appeared to have some benefits at eight to twelve years. Operative treatment was associated with a higher risk of complications but a reduced prevalence of posttraumatic arthritis evident on follow-up radiographs. LEVEL OF EVIDENCE: Therapeutic level II. See instructions for authors for a complete description of levels of evidence.

Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study.

BACKGROUND: Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities. METHODS: Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons-Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up. RESULTS: The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work. CONCLUSIONS: The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Interobserver reliability and intraobserver reproducibility of three radiological classification systems for intra-articular calcaneal fractures.

BACKGROUND: The management of intra-articular calcaneal fractures is difficult. One aspect for successful management is the use of a reliable and reproducible fracture classification system (FCS). The purpose of this study was to evaluate the interobserver reliability and intraobserver reproducibility of Letournel, Sanders, and Zwipp classification systems on CT scan and the Bohler's angle measurement on plain X-ray. Furthermore, we studied if the addition of a CT scan to the plain X-ray influenced the evaluation of fracture extension to the calcaneocuboid joint. METHODS: The CT scan and plain X-ray images of 51 intra-articular calcaneal fractures were evaluated two times by three observers (two radiologists and one orthopedic surgeon) within a 5-month interval. The interobserver reliability was measured using the Fleiss kappa while the intraobserver reproducibility was measured using the Cohen's kappa. RESULTS: The mean kappa values for the interobserver reliability and intraobserver reproducibility of the Sanders classification were 0.25 and 0.39, respectively, of Zwipp classification were 0.24 and 0.16, respectively, while those of the Letournel classification were 0.50 and 0.42, respectively. For the Böhler's angle, the mean kappa values for the interobserver reliability and intraobserver reproducibility were 0.34 and 0.32, respectively. The addition of CT scan images to plain X-ray found a higher incidence of calcaneocuboid joint involvement. CONCLUSION: Clinicians should be aware of the limitation regarding the interobserver reliability and intraobserver reproducibility of the Letournel, Sanders and Zwipp classification systems for calcaneal fractures. Future studies should attempt to improve the present classification systems.