Are current foot- and ankle outcome measures appropriate for the evaluation of treatment for osteoarthritis of the ankle?: Evaluation of ceiling effects in foot- and ankle outcome measures. Comparison of commonly used orthopaedic outcome measures using palm-top computers and paper surveys. A systematic review of outcome tools used to measure lower leg conditions. Evaluation of the foot and ankle outcome score in patients with osteoarthritis of the ankle. Use of Condition-Specific Patient-Reported Outcome Measures in Clinical Trials among Patients with Wrist Osteoarthritis: A Systematic Review Clinical interpretation of computerized adaptive test outcome measures in patients with foot/ankle impairments. Evaluation of the Dutch version of the Foot and Ankle Outcome Score (FAOS): responsiveness and Minimally Important Change No improvement in reducing outliers in coronal axis alignment with patient-specific instrumentation The comprehensive cohort model in a pilot trial in orthopaedic trauma Factors predicting the outcome of customised foot orthoses in patients with rheumatoid arthritis: a prospective cohort study Reliability and Validity of 6 Measures of Pain, Function, and Disability for Ankle Arthroplasty and Arthrodesis A Randomized Controlled Trial Comparing Rehabilitation Efficacy in Chronic Ankle Instability. Validity and responsiveness of the ankle function score after acute ankle injury. Validation of the Foot and Ankle Outcome Score in Adult Acquired Flatfoot Deformity Minimal clinically important differences of 3 patient-rated outcomes instruments. Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial
BACKGROUND Many PROMs used for evaluation of ankle  osteoarthritis  are not vali date d for this purpose . We hypothesize that frequently used PROMs have an early ceiling or floor effect . METHODS We prospect ively collected data from patients with ankle osteoarthritis between 2011 and 2013 . At baseline visit patients completed the Foot and Ankle Outcome Score , the Ankle Osteoarthritis Score , the American Orthopaedic Foot and Ankle Society scale , a visual analogue scale for pain and quality of life . Outcomes were analyzed for floor or ceiling effects . RESULTS 197 patients were included in the study . A floor effect was present for the AOFAS and VAS for pain in all groups . Floor and ceiling effect are absent for the FAOS outcome measure for all groups . CONCLUSIONS Physicians should be aware of floor or ceiling effects when evaluating treatment using patient reported outcome measures . The FAOS outcome measure lacks early ceiling or floor effects INTRODUCTION Measuring  patient-perceived outcomes  following orthopaedic procedures have become an important component of clinical research and patient care . General and disease-specific outcomes measures have been developed and applied in orthopaedics to assess the patients ' perceived health status . Unfortunately , paper-based , self-administered instruments remain inefficient for collecting data because of : ( a ) missing data ( b ) respondent error , and ( c ) the costs to administer and enter data . OBJECTIVE To study the comparability of palm-top computer devices and paper-pencil self-administered question naires in the collection of health-related quality of life ( HRQL ) information from patients . METHODS The comparability of administering HRQL question naires using palm-top computer and traditional paper-based forms was tested in a sample of 96 patients with complaints of hip and /or knee pain . Each patient completed mailed versions of the Medical Outcomes Study ( MOS ) , 36-item Health Survey ( SF-36 ) , and Western Ontario and McMasters University Arthritis Index ( WOMAC ) three weeks prior to presenting to clinic . At the clinic they were asked to complete the same outcomes measures using the palm-top computer or a paper- and -pencil version . ANALYSIS In the analysis , scale distributions , floor and ceiling effects , internal consistency and retest reliability of scales were compared across the two data collection methods . Because the baseline characteristics of the groups were not strictly comparable according to age , the data were analyzed for the entire sample and stratified according to age . RESULTS Few statistically significant differences were found for the means , variances and intra-class correlation coefficients between the methods of administration . While the scale distribution between the two methods was comparable , the internal consistency of the scales was dissimilar . CONCLUSIONS Administration of HRQL question naires using portable palm-top computer devices has the potential advantage of decreased cost and convenience . These data lend some support for the comparability of palm-top computers and paper surveys for outcomes measures widely used in the field of orthopaedic surgery . The present study identified the lack of reliability across modes of administration that requires further study in a r and omized comparability trial . These mode effects are important for orthopaedic surgeons to appreciate before implementing innovative data -capture technologies in their practice BACKGROUND CONTEXT A variety of self-report and physical performance-based outcome measures are commonly used to assess progress and recovery in the lower leg , ankle , and foot . A requisite attribute of any outcome measure is its ability to detect change in a condition , a construct known as " responsiveness " . There is a lack of consistency in how responsiveness is defined in all outcome measures . PURPOSE The purpose of this study was to review the currently used recovery outcome measures for lower leg , ankle and foot conditions in order to determine and report recommended responsiveness values . METHODS A systematic literature search that included electronic search es of PubMed , CINAHL and SportD iscus as well extensive cross-referencing was performed in January , 2013 . Studies were included if each involved : 1 ) a prospect i ve , longitudinal study of any design ; 2 ) any condition associated with the lower leg , ankle or foot ; 3 ) a measure of responsiveness ; and 4 ) was an acceptable type of outcome measure ( eg . self-report , physical performance , or clinician report ) . The quality of the included articles was assessed by two independent authors using the responsiveness sub-component of the Consensus-based St and ards for the selection of health Measurement Instruments ( COSMIN ) . RESULTS Sixteen different studies met the inclusion criteria for this systematic review . The most commonly used outcome measures were the Foot and Ankle Ability Measure and the Lower Extremity Functional Scale . Responsiveness was calculated in a variety of methods including effect size , st and ardized response mean , minimal clinical ly important difference/ importance , minimal detectable change , and minimal important change . CONCLUSION Based on the findings of this systematic review there is a lack of consistency for reporting responsiveness among recovery measures used in the lower leg , ankle or foot studies . It is possible that the variability of conditions that involve the lower leg , ankle and foot contribute to the discrepancies found in reporting responsiveness values . Further research must be conducted in order to st and ardize reporting measures for responsiveness . LEVEL OF EVIDENCE 2a The foot and ankle outcome score ( FAOS ) has been evaluated for many conditions of the foot and ankle . We evaluated its construct validity in 136 patients with osteoarthritis of the ankle , its content validity in 37 patients and its responsiveness in 39 . Data were collected prospect ively from the registry of patients at our institution . All FAOS subscales were rated relevant by patients . The Pain , Activities of Daily Living , and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2 . All subscales except Symptoms were responsive to change after surgery . We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle . However , some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments Background . This paper aim ed to identify condition-specific patient-reported outcome measures used in clinical trials among people with wrist osteoarthritis and summarise empirical peer- review ed evidence supporting their reliability , validity , and responsiveness to change . Methods . A systematic review of r and omised controlled trials among people with wrist osteoarthritis was undertaken . Studies reporting reliability , validity , or responsiveness were identified using a systematic reverse citation trail audit procedure . Psychometric properties of the instruments were examined against predefined criteria and summarised . Results . Thirteen clinical trials met inclusion criteria . The most common patient-reported outcome was the disabilities of the arm , shoulder , and h and question naire ( DASH ) . The DASH , the  Michigan H and Outcomes Question naire ( MHQ ) , the  Patient Evaluation Measure ( PEM ) , and the  Patient-Reported Wrist Evaluation ( PRWE ) had evidence supporting their reliability , validity , and responsiveness . A post-hoc review of excluded studies revealed the AUSCAN Osteoarthritis H and Index as another suitable instrument that had favourable reliability , validity , and responsiveness . Conclusions . The DASH , MHQ , and AUSCAN Osteoarthritis H and Index instruments were supported by the most favourable empirical evidence for validity , reliability , and responsiveness . The PEM and PRWE also had favourable empirical evidence reported for these elements . Further psychometric testing of these instruments among people with wrist osteoarthritis is warranted STUDY DESIGN Prospect i ve cohort study of 10 287 patients with foot/ankle impairments receiving outpatient physical therapy .  OBJECTIVES To describe meaningful interpretations of functional status ( FS ) outcomes measures , estimated using a body-part-specific computerized adaptive test ( CAT ) . BACKGROUND Increased use of CATs to generate outcome measures in rehabilitation has stimulated questions concerning score interpretation . Identifying meaningful intra-individual change and reporting clinical interpretation of those generated outcomes are essential to advance the quality of rehabilitation practice . METHODS We performed 4 approaches to clinical ly interpret outcomes data . First , we used the st and ard error of the estimate to construct a 90 % confidence interval for each CAT estimated score . Second , we presented the percentile rank of FS scores . Third , we used 2 threshold approaches to define individual-patient-level change : statistically reliable change and clinical ly important change . Last , we illustrated a functional staging method . RESULTS Precision of a single score was estimated by an FS score of + /-4 . Based on score distribution , percentile ranks at 25th , 50th , and 75th percentiles corresponded to intake FS scores of 38 , 47 , and 57 , and discharge FS scores of 52 , 64 , and 77 , respectively . Minimal detectable change supported 7 or more FS change units out of 100 represented statistically reliable change , and ROC analyses supported 8 or more FS change units represented minimal clinical ly important improvement . Using a functional staging system , we established 5 hierarchical functional status levels . CONCLUSION CAT-generated outcome measures can be interpreted to improve clinical interpretation and to assist clinicians in using patient-reported outcomes during therapy practice Purpose The aim of this study was to evaluate the responsiveness of the Foot and Ankle Outcome Score ( FAOS ) and provide data on the Minimally Important Change ( MIC ) in patients 1 year after hindfoot and ankle surgery . Methods Prospect i ve pre-operative and 1 year post-operative FAOS scores were collected from 145 patients . A patient ’s global assessment and a longitudinal derived Function Change Score were used as external anchors . To assess responsiveness , effect sizes ( ES ) and St and ardized Response Means ( SRM ) were calculated and hypotheses on their magnitudes were formulated . Additional ROC curve analysis was performed , and the Area Under the Curve ( AUC ) was calculated as a measure of responsiveness . MIC values were estimated using two different methods : ( 1 ) the mean change method and ( 2 ) the optimal cut-off point of the ROC curve . Results Responsiveness was supported by confirmation of 84 % of the hypothesized ES and SRM and almost all AUCs exceeding 0.70 . MIC values ranged from 7 ( symptoms ) to 38 ( sport ) points . They varied between calculation methods and were negatively associated with baseline values . A considerable amount of MIC values did not exceed the smallest detectable change limit , indicating that the FAOS is more suitable at group level than for longitudinally following individual patients . Conclusions The FAOS demonstrated good responsiveness in patients 1 year after hindfoot and ankle surgery . Due to their wide variation , MIC estimates derived in this study should be interpreted with caution . However , these estimates can be of value to facilitate sample size calculation in future studies .Level of evidence Diagnostic study , Level Purpose and hypothesisPatient-specific instrumentation ( PSI ) uses 3D preoperative imaging to produce individualized cutting blocks specific to patients ’ anatomy and according to the preoperative plan with the aim to reduce the number of mechanical leg alignment ( MLA ) outliers , to improve implant positioning and to decrease surgery time . The primary purpose of this study was to investigate the efficacy of a specific PSI in comparison with st and ard instrumentation ( SI ) in reducing the number of MLA outliers . It was hypothesized that the number of MLA outliers would be significantly lower in the PSI group . Methods A multicenter r and omized controlled trial was implemented . There were 59 patients in the PSI group and 66 in the SI group . The absolute number of outliers outside the ± 3 ° target neutral MLA was compared between the groups with a Chi-square test . As secondary outcomes , the Knee Society Score ( KSS ) and the Knee Injury and Osteoarthritis Outcome Score ( KOOS ) were compared between the groups preoperatively and at 90-day follow-up . Results There were 15 ( 26.3 % ) MLA outliers in the PSI group and 8 ( 12.3 % ) in the SI group . The number of outliers was not independent from the group ( X2(1 ) = 3.8 , p = 0.04 ; Relative risk = 1.5 ) . Preoperatively , there were no significant differences between the groups when comparing their KSS and KOOS sub-scores . At 90 days postoperatively , the patients in the SI group showed better KOOS- Quality of Life ( KOSS-QOL ) in comparison with the PSI group ( p < 0.0001 ) . Conclusion The use of PSI did not significantly reduce the number of MLA outliers in comparison with SI . There were no differences when comparing the achieved mean MLA of both groups . Level of evidence Level I , prospect i ve r and omized controlled trial Background The primary aim of this study was to provide an estimate of effect size for the functional outcome of operative versus non-operative treatment for patients with an acute rupture of the Achilles tendon using accelerated rehabilitation for both groups of patients . The secondary aim was to assess the use of a comprehensive cohort research design ( i.e. a parallel patient-preference group alongside a r and omised group ) in improving the accuracy of this estimate within an orthopaedic trauma setting . Methods Pragmatic r and omised controlled trial and comprehensive cohort study within a level 1 trauma centre . Twenty r and omised participants ( 10 operative and 10 non-operative ) and 29 preference participants ( 3 operative and 26 non-operative ) . The ge range was 22 - 72 years and 37 of the 52 patients were men . All participants had an acute rupture of their Achilles tendon and no other injuries . All of the patients in the operative group had a simple end-to-end repair of the tendon with no augmentation . Both groups then followed the same eight-week immediate weight-bearing rehabilitation programme using an off-the-shelf orthotic .  The disability rating index ( DRI ; primary outcome ) , EQ-5D , Achilles Total Rupture Score and complications were assessed ed at two weeks , six weeks , three months , six months and nine months after initial injury . Results At nine months , there was no significant difference in DRI between patients r and omised to operative or non-operative management . There was no difference in DRI between the r and omised group and the parallel patient preference group . The use of a comprehensive cohort of patients did not provide useful additional information as to the treatment effect size because the majority of patients chose non-operative management . Conclusions Recruitment to clinical trials that compare operative and non-operative interventions is notoriously difficult ; especially within the trauma setting . Including a parallel patient preference group to create a comprehensive cohort of patients has been suggested as a way of increasing the power of such trials . In our study , the comprehensive cohort model doubled the number of patients involved in the study . However , a strong preference for non-operative treatment meant that the increased number of patients did not significantly increase the ability of the trial to detect a difference between the two interventions .Trial registration IS RCT N : IS RCT Background Conservative management of foot problems in patients with rheumatoid arthritis ( RA ) may consist of the prescription of customised foot orthoses . Indications for foot orthoses are not clear and the effectiveness of the intervention is highly variable among patients . Knowledge on which patients benefit the most from foot orthoses can help to select patients eligible for this type of intervention . The objective of the present study was to determine clinical and demographic factors that predict the outcome of customised foot orthoses on pain and disability in patients with RA . Methods A total of 135 RA patients who were supplied with customised foot orthoses were included in this prospect i ve cohort study . Pain and disability were measured before and after the intervention period using a Numeric Rating Scale ( NRS ) for foot pain , the Foot Function Index ( FFI ) , the Western Ontario and McMasters Universities Osteoarthritis Index ( WOMAC ) and a 10-meter walking test . The intervention period consisted of one or more appointments with the podiatrist during which the foot orthoses were customised . Swollen foot joint count , foot deformity scores , forefoot peak pressure , disease duration , age , gender , body mass index and baseline values of the outcome measures were selected as potential factors predicting outcome . Multivariate linear regression analyses were performed to determine factors associated with change in pain and disability ( at P < 0.05 ) . Results Disease duration was negatively associated with the change scores in NRS foot pain ( P = 0.018 ) , WOMAC pain ( P = 0.001 ) , FFI disability ( P = 0.003 ) and WOMAC physical function ( P = 0.002 ) . Age was negatively associated with the change score in 10 meter walking time ( P = 0.008 ) . For all outcome measures baseline values were positively associated with the change scores ( P < 0.001 ) . Conclusions Shorter disease duration predicted greater improvements in self-reported foot pain and disability , and younger age predicted greater improvements in walking time after intervention with foot orthoses . Also , higher baseline values of pain and disability predicted greater improvements . Referral for conservative management with foot orthoses in the early stage of RA seems important when aim ing to achieve reduction in pain and improvement in daily activities Background : Patient-reported outcome measures are increasingly used evaluating clinical care . Many measures used to assess operative hindfoot interventions vary in content , and some have not been psychometrically vali date d in this population . The purpose of this study was to compare measurement properties of  6 lower-extremity patient-reported outcome measures  , and to evaluate their reliability and validity in light of patients ’ preferences . Methods : Cross-sectional survey of 42 preoperative and 100 postoperative patients completed 6 lower-extremity outcome measures  on 2 occasions : Foot Function Index ( FFI ) , Ankle Osteoarthritis Scale ( AOS ) , patient-reported items of the  American  Orthopaedic Foot & Ankle Society Question naire ( AOFAS ) , Lower Extremity Functional Scale ( LEFS ) , Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , and the Short Musculoskeletal Function Assessment ( SMFA ) , as well as measures of preference , and symptoms . Results : Internal consistency was good to excellent for all scales and subscales ( α = .84-.97 ; ICC [ 2,1 ] = .81-.96 ) . Correlations between scales ranged from .50 ( WOMACStiffness and FFIActivity Limitations ) to .92 ( LEFS and SMFAOverall , WOMACPain and AOSOverall , FFIOverall and AOFASOverall ) . Higher correlations occurred within instruments ( r = .97 AOSPain and AOSOverall ) and between similar subscales from different instruments ( r = .91 WOMACPain and AOSPain ) . Construct validity showed moderate to high correlations to global ratings of Pain , Stiffness , and difficulty performing Daily Activities . The highest correlations ( r > .75 ) occurred between Pain and AOSOverall ( r = .84 ) , stiffness and WOMACStiffness ( r = .81 ) , and Daily Activities and AOSDisability ( r = .87 ) . Patients rated instruments by preference . FFI , WOMAC , LEFS , and SMFA rated favorably for length . FFI , WOMAC , LEFS , and AOFAS rated high for underst and ability . FFI was rated by postoperative patients as most likely to capture change due to surgery . SMFA rated the best overall . Conclusions : Direct comparison of instruments revealed similarity between scales in construct validity and reliability . Patient preferences supported the use of these scales . Foot-specific instruments offered no clear advantage over lower-extremity instruments . Level of Evidence : Level II , prospect i ve comparative study CONTEXT There is minimal patient-oriented evidence regarding the effectiveness of interventions targeted to reduce symptoms associated with chronic ankle instability ( CAI ) . In addition , clinicians aim ing to prioritize care by implementing only the most effective components of a rehabilitative program have very little evidence on comparative efficacy . OBJECTIVE To assess the comparative efficacy of 2 common ankle rehabilitation techniques ( wobble-board [ WB ] balance training and ankle strengthening using resistance tubing [ RT ] ) using patient-oriented outcomes . DESIGN R and omized controlled trial . SETTING Laboratory . PATIENTS 40 patients with CAI r and omized into 2 treatment groups :  RT and WB .  CAI inclusion criteria included a history of an ankle sprain , recurrent " giving way , " and a Cumberl and Ankle Instability Tool ( CAIT ) score ≤25 . INTERVENTIONS Participants completed 5 clinician-oriented tests  ( foot-lift test , time-in-balance , Star Excursion Balance Test , figure-of-8 hop , and side-hop ) and 5  patient-oriented question naires ( CAIT , Foot and Ankle Ability Measure [ FAAM ] , Activities of Daily Living [ ADL ] and FAAM Sport scale , Short-Form 36 [ SF-36 ] , and Global Rating of Function [ GRF ] ) . After baseline testing , participants completed 12 sessions over 4 wk of graduated WB or RT exercise , then repeated baseline tests . MAIN OUTCOME MEASURES For each patient- and clinician-oriented test , separate 2 × 2 RMANOVAs analyzed differences between groups over time ( alpha set at P = .05 ) . RESULTS There was a significant interaction between group and time for the FAAM-ADL ( P = .04 ) . Specifically , the WB group improved postintervention ( P < .001 ) whereas the RT group remained the same ( P = .29 ) . There were no other significant interactions or significant differences between groups ( all P > .05 ) . There were significant improvements postintervention for the CAIT , FAAM-Sport , GRF , SF-36 , and all 5 clinician-oriented tests ( all P < .001 ) . CONCLUSIONS A single-exercise 4-wk intervention can improve patient- and clinician-oriented outcomes in individuals with CAI . Limited evidence indicates that WB training was more effective than RT . LEVEL OF EVIDENCE Therapy , level 1b The purpose of this study was to examine prognostic validity , concurrent validity and responsiveness of ankle function score ( AFS ) for patients with acute ankle injury . In a prospect i ve cohort study , AFS was compared with Olerud and Mol and er ankle score ( OMAS ) , patient-specific complaints ( PSC ) , and global perceived effect . Sensitivity and specificity were calculated to estimate prognostic validity ; correlation was calculated for concurrent validity . Effect Size , St and ardized Response Mean , and Responsiveness Ratio were calculated to estimate responsiveness . The sensitivity of AFS was 76 % and the specificity was 57 % . Correlation between AFS and OMAS at baseline , end of treatment and difference was 0.82 , 0.70 and 0.79 , respectively . Outcomes for responsiveness of AFS were comparable to outcomes for OMAS and PSC . This study found limited evidence for the AFS as a prognostic and evaluative instrument . The AFS is a simple instrument based on basic functional outcomes ( pain , stability , weight bearing , swelling and gait ) and may be used in addition to subjective clinical judgment as a prognostic and evaluative tool for recovery after acute ankle injury Introduction : The American Orthopaedic Foot and Ankle Society ( AOFAS ) Ankle-Hindfoot Score has been under recent scrutiny . The Foot and Ankle Outcome Score ( FAOS ) is an alternative subjective survey , assessing outcomes in 5 subscales . It is vali date d for lateral ankle instability and hallux valgus patients . The aim of our study was to vali date the FAOS for assessing outcomes in flexible adult acquired flatfoot deformity ( AAFD ) . Methods : Patients from the authors ’ institution diagnosed with flexible AAFD from 2006 to 2011 were eligible for the study . In all , 126 patients who completed the FAOS and the Short-Form 12 ( SF-12 ) on the same visit were included in the construct validity component . Correlation was deemed moderate if the Spearman ’s correlation coefficient was .4 to .7 . Content validity was assessed in 63 patients by a question naire that asked patients to rate the relevance of each FAOS question , with a score of 2 or greater considered acceptable . Reliability was measured using intraclass correlation coefficients ( ICCs ) in 41 patients who completed a second FAOS survey . In 49 patients , preoperative and postoperative FAOS scores were compared to determine responsiveness . Results : All of the FAOS subscales demonstrated moderate correlation with 2 physical health related SF-12 domains . Mental health related domains showed poor correlation . Content validity was high for the Quality of Life ( QoL ; mean 2.26 ) and Sports/Recreation subscales ( mean 2.12 ) . All subscales exhibited very good test – retest reliability , with ICCs of .7 and above . Symptoms , QoL , pain , and daily activities ( ADLs ) were responsive to change in postoperative patients ( P < .05 ) . Conclusion : This study has vali date d the FAOS for AAFD with acceptable construct and content validity , reliability , and responsiveness . Given its previous validation for patients with ankle instability and hallux valgus , the additional findings in this study support its use as an alternative to less reliable outcome surveys . Level of Evidence : Level II , prospect i ve comparative study PURPOSE Patient-rated instruments are increasingly used to measure orthopedic outcomes . However , the clinical relevance of modest score changes on such instruments is often unclear . This study was design ed to define the minimal clinical ly important differences ( MCIDs ) of the Disabilities of the Arm , Shoulder , and H and ( DASH ) , QuickDASH ( subset of DASH ) , and Patient-Rated Wrist Evaluation ( PRWE ) question naires for atraumatic conditions of the h and , wrist , and forearm . METHODS We prospect ively analyzed 102 patients undergoing nonoperative treatment for isolated tendinitis , arthritis , or nerve compression syndromes from the forearm to the h and . By phone , patients completed the DASH , QuickDASH , and PRWE at enrollment and at 2 weeks ( n = 78 used in the analysis ) and 4 weeks ( n = 24 used in the analysis ) after initiating treatment . Patients reporting clinical improvement each contributed a single data point categorized as no change ( n = 41 ) , minimal improvement ( n = 30 ) , or marked improvement ( n = 31 ) via a vali date d anchor-based approach . We calculated the MCID as the mean change score for each outcome measure in the minimal improvement group . RESULTS The MCID ( 95 % confidence interval ) for the DASH was 10 ( 5 - 15 ) . The MCID for the QuickDASH was 14 ( 9 - 20 ) . The MCID was 14 ( 8 - 20 ) for the PRWE . The MCID values were significantly different from changes in these outcome measures at times of either no change or marked improvement . The MCID values positively correlated with baseline outcome measure scores to a greater degree than final outcome measure scores . CONCLUSIONS Longitudinal changes on the DASH of 10 points , on the QuickDASH of 14 points , and on the PRWE of 14 points represent minimal clinical ly important changes . We recommend application of these MCID values for group-level analysis when conducting research and interpreting data examining groups of patients as opposed to assessing individual patients . These MCID values may provide a basis for sample size calculations for future investigation using these common patient-rated outcome measures . TYPE OF STUDY /LEVEL OF EVIDENCE Diagnostic III BACKGROUND Despite evidence that shared decision-making tools for treatment decisions improve decision quality and patient engagement , they are not commonly employed in orthopaedic practice . The purpose of this study was to evaluate the impact of decision and communication aids on patient knowledge , efficiency of decision making , treatment choice , and patient and surgeon experience in patients with osteoarthritis of the hip or knee . METHODS One hundred and twenty-three patients who were considered medically appropriate for hip or knee replacement were r and omized to either a shared decision-making intervention or usual care . Patients in the intervention group received a digital video disc and booklet describing the natural history and treatment alternatives for hip and knee osteoarthritis and developed a structured list of questions for their surgeon in consultation with a health coach .  Patients in the control group received information about the surgeon 's practice . Both groups reported their knowledge and stage in decision making and their treatment choice , satisfaction , and communication with their surgeon . Surgeons reported the appropriateness of patient questions and their satisfaction with the visit . The primary outcome measure tracked whether patients reached an informed decision during their first visit . Statistical analyses were performed to evaluate differences between groups . RESULTS Significantly more patients in the intervention group ( 58 % ) reached an informed decision during the first visit compared with the control group ( 33 % ) ( p = 0.005 ) . The intervention group reported higher confidence in knowing what questions to ask their doctor ( p = 0.0034 ) . After the appointment , there was no significant difference between groups in the percentage of patients choosing surgery ( p = 0.48 ) . Surgeons rated the number and appropriateness of patient questions higher in the intervention group ( p < 0.0001 ) , reported higher satisfaction with the efficiency of the intervention group visits ( p < 0.0001 ) , and were more satisfied overall with the intervention group visits ( p < 0.0001 ) . CONCLUSIONS Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons . These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice Introduction While only 15–20 % of patients with foot and ankle injuries presenting to urgent care centers have clinical ly significant fractures , most undergo radiography . We examined the impact of electronic point-of-care clinical decision support ( CDS ) on adherence to the Ottawa Ankle Rules ( OAR ) , as well as use and yield of foot and ankle radiographs in patients with acute ankle injury . Methods We obtained institutional review board approval for this r and omized controlled study performed April 18 , 2012—December 15 , 2013 . All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were r and omized to either receive or not receive CDS , based on the OAR and integrated into the physician order-entry system , with feedback at the time of imaging order . If the patient met OAR low-risk criteria , providers were advised against imaging and could either cancel the order or ignore the alert . We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports review ed for those who were eligible . Chi-square was used to compare adherence to the OAR ( primary outcome ) , radiography utilization rate and radiography yield of foot and ankle imaging ( secondary outcomes ) between the intervention and control groups . Results Of 14,642 patients seen at urgent care during the study period , 613 ( 4.2 % , representing 632 visits ) presented with acute ankle injury and were eligible for application of the OAR ; 374 ( 59.2 % ) of these were seen by control-group providers . In the intervention group , CDS adherence was higher for both ankle ( 239/258=92.6 % vs. 231/374=61.8 % , p=0.02 ) and foot radiography ( 209/258=81.0 % vs. 238/374=63.6 % ; p<0.01 ) . However , ankle radiography use was higher in the intervention group ( 166/258=64.3 % vs. 183/374=48.9 % ; p<0.01 ) , while foot radiography use ( 141/258=54.6 % vs. 202/374=54.0 % ; p=0.95 ) was not . Radiography yield was also higher in the intervention group ( 26/307=8.5 % vs. 18/385=4.7 % ; p=0.04 ) . Conclusion Clinical decision support , previously demonstrated to improve guideline adherence for high-cost imaging , can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increased imaging yield
A considerable variety of outcome measurement tools are used in the foot and ankle clinical literature , with a small proportion used consistently .
The AOFAS scales continue to be used at a high rate relative to other scales that have been vali date d. Data from the present study underscore the need for a paradigm shift toward the use of consistent , valid , and reliable outcome measures for studies of foot and ankle procedures and disorders .
It is not clear which existing vali date d outcome instruments will emerge as widely used and clinical ly meaningful .
BACKGROUND In the orthopaedic literature , there is a wide range of clinical outcome measurement tools that have been used in evaluating foot and ankle procedures , disorders , and outcomes , with no broadly accepted consensus as to which tools are preferred .
The purpose of this study was to determine the frequency and distribution of the various outcome instruments used in the foot and ankle literature , and to identify trends for use of these instruments over time .