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.

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.

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.

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.

Distal Fibula Fractures-Intramedullary Fixation Versus Plating: A Systematic Review and Meta-analysis of Randomized Control Trials.

PURPOSE: The aim of the present study is to compare the functional scores and complications of intramedullary fixation versus plate osteosynthesis of distal fibular fractures in adults. METHODS: Study was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses format from MEDLINE, Embase, Ovid, and Cochrane databases. The included articles were assessed according to the risk of bias assessment tool by Cochrane collaboration. RESULTS: A total of 5 randomized control trials were included for quantitative review. Random sequence generation and allocation concealment of the study subjects were the strengths of all the included studies. There was high heterogeneity among the included studies (I2 > 75%). There was no significant difference between the Olerud-Molander scores in both the groups but the trend favored the intramedullary nailing of distal fibula (mean difference of 3.42, 95% confidence interval [CI] of 8.90). Complications were significantly lesser in the intramedullary group across the studies (odds ratio 0.26, 95% CI of 0.81). CONCLUSION: Intramedullary nailing of fibula with the use of modern locking fibular nails is an alternative to fibular plating for unstable distal fibular fractures in properly selected cases. There remains the need for standardizing the method of operative treatment of distal fibular fractures which can be done by a well-planned large-scale prospective study design. LEVEL OF EVIDENCE: Level 1.

Radiological malunion after ankle fractures in older adults : definitions and new thresholds derived from clinical outcome data from the AIM trial.

AIMS: The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence. METHODS: Radiological (absolute radiological measurements aided by computer software) and clinical (clinical interpretation of radiographs) definitions of malunion were compared within the Ankle Injury Management (AIM) trial cohort, including people aged ≥ 60 years with an unstable ankle fracture. Linear regressions were used to explore the relationship between radiological malunion (RM) at six months and changes in function at three years. Function was assessed with the Olerud-Molander Ankle Score (OMAS), with a minimal clinically important difference set as six points, as per the AIM trial. Piecewise linear models were used to investigate new radiological thresholds which better explain symptom impact on ankle function. RESULTS: Previously described measures of RM and surgeon opinion of clinically significant malunion (CSM) were shown to be related but with important differences. CSM was more strongly related to outcome (-13.9 points on the OMAS; 95% confidence interval (CI) -21.9 to -5.4) than RM (-5.5 points; 95% CI -9.8 to -1.2). Existing malunion thresholds for talar tilt and tibiofibular clear space were shown to be slightly conservative; new thresholds which better explain function were identified (talar tilt > 2.4°; tibiofibular clear space > 6 mm). Based on this new definition the presence of RM had an impact on function, which was statistically significant, but the clinical significance was uncertain (-9.1 points; 95% CI -13.8 to -4.4). In subsequent analysis, RM of a posterior malleolar fracture was shown to have a statistically significant impact on OMAS change scores, but the clinical significance was uncertain (-11.6 points; 95% CI -21.9 to -0.6). CONCLUSION: These results provide clinical evidence which supports the previously accepted definitions. Further research to investigate more conservative clinical thresholds for malunion is indicated.Cite this article: Bone Jt Open 2022;3(10):841-849.

Functional outcome of routine versus on-demand removal of the syndesmotic screw: a multicentre randomized controlled trial.

AIMS: The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. METHODS: Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). RESULTS: There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). CONCLUSION: ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709-1716.

Impact of metabolic syndrome on patient outcomes of supination-external rotation ankle fracture.

Metabolic syndrome has been known as a risk factor for morbidity following orthopedic procedures, yet its impact on surgical treatment of ankle fractures remains unclear. The aim of this study was to compare the patient outcomes of surgical treatment of supination-external rotation ankle fractures in patients with and without metabolic syndrome. This study was designed as a retrospective matched case-control study. Forty-nine patients with supination-external rotation ankle fracture and metabolic syndrome were age-, sex-, and fracture type-matched with 49 controls without metabolic syndrome. Olerud-Molander Ankle Score (OMAS), Visual Analog Scale (VAS), Kellgren and Lawrence (K&L) scale, and complications were assessed at final follow-up. The mean postoperative follow-up was 19.5 months (range, 13-44). The OMAS measurements in the metabolic syndrome group were lower than those in the control group (p = 0.006) and the VAS for pain measurements in the metabolic syndrome group were greater than those in the control group (p < 0.001). The K&L scale and complications did not differ significantly between the two groups. Patients with metabolic syndrome are at risk for higher pain scores and lower functional outcomes after surgical treatment for supination-external rotation ankle fracture. These results suggest that metabolic syndrome should be treated together with ankle fractures.

Translation, cross-cultural adaptation, reliability and validity of the Turkish version of the Olerud-Molander Ankle Score (OMAS).

OBJECTIVE: The aim of this study was to translate and culturally adapt the Olerud-Molander Ankle Score (OMAS) into Turkish and to assess its reliability and validity. METHODS: The Turkish version of the OMAS (OMAS-Tr) was developed after the translation and back-translation, which included the stages recommended by Beaton. The OMAS-Tr was administered to one hundred patients (49 females, 51 males; average age: 42.3 ± 17.7; range 16-81 years) with malleolar fractures. The OMAS-Tr was completed twice by each participant at 7- to 10-days intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbach's alpha evaluated internal consistency. The external validity was evaluated with correlations between the Turkish version of the Foot and Ankle Ability Measure (FAAM) and the Turkish version of the SF-12 questionnaire. The distribution of floor and ceiling effects was also analyzed. RESULTS: The internal consistency (Cronbach's α = 0.84) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 8.6 ± 1.4 days. The mean and standard deviation of the first and second assessments of the OMAS-Tr were 74.1 ± 23.7 and 75.7 ± 23.9, respectively. There was a strong correlation between the OMAS-Tr and the FAAM subscales on activities of daily living and sports (r = 0.86, r = 0.83; p < 0.001, respectively). The OMAS-Tr displayed very good to good correlation with the SF-12 physical component score and the SF-12 mental component score (r = 0.72, r = 0.60, p < 0.001, respectively). CONCLUSION: OMAS-Tr was a valid and reliable tool to assess ankle fracture-related problems. Nonetheless, further studies are needed to assess its responsiveness. LEVEL OF EVIDENCE: Level III, diagnostic study.

Distal tibiofibular synostosis after surgically resolved ankle fractures: An epidemiological, clinical and morphological evaluation of a patient sample.

INTRODUCTION: Ankle fractures comprise a highly morphologically and etiologically diverse group of injuries, which includes various degrees of impairment of bone and ligamentous structures. The complete synostosis and incomplete bony bridging of tibiofibular syndesmosis are among the local late complications after surgically treated ankle fractures. PATIENTS AND METHOD: 269 patients were evaluated, including 203 patients with Weber type-B fractures, and 66 patients with Weber type-C fractures. All patients underwent ankle radiography at standard intervals (post-operatively, 6 and 12 weeks, 6 and 12 months). The final assessment one year after osteosynthesis was performed. The study analyzed age, sex, fracture morphology, the location and morphology of ossification, functional outcomes and subjective evaluations of patient status. RESULTS: As risk factors there were found male sex, tibiotalar dislocation, syndesmotic screw fixation and Weber type-C fractures. The severity of subjective difficulties and objective status were not dependent on the size of distal tibiofibular synostosis. DISCUSSION AND CONCLUSION: Despite relatively extensive imaging findings of complete synostosis or incomplete bony bridging, they only limited functional outcomes to a minimal extent.