Foot and ankle assessments fail to capture patient concerns

By Lynda Williams, Senior medwireNews Reporter

Commonly used clinical measurements of foot and ankle outcome do not reflect patient concerns, missing the impact of age and gender on how patients define treatment success, US researchers caution.

"We discovered that up to half of each survey instrument from two commonly used physician-derived foot and ankle rating scales may be composed of elements that are not of primary importance to patients," report Judith Baumhauer (University of Rochester, New York) and co-workers.

The team used patient feedback to construct a 20-item survey of the most important outcomes in the treatment of their foot or ankle issue. In all, 783 patients were asked to identify the top five factors and rank them in order of importance.

Limited walking, activity-related pain, constant pain, difficulty with prolonged standing, and inability to work or do housework were the most important issues identified by patients overall. However, women placed difficulty fitting into shoes into the top five, whereas men considered this issue to be of less importance than inability to work or do housework.

Patients aged less than 55 years significantly differed from older patients with regard to the most important factors, and were significantly more likely to place inability to work or play sports in the top five issues. Younger patients were also more likely to rate constant pain as important than older patients (25.8 vs 16.6%).

Although patients aged 55 years or older were more likely to be troubled by recurrent foot or ankle skin sores and infection than younger patients, only a small proportion of either group placed this in the top five (4.4 vs 1.3%).

Baumhauer and team compared the five most important factors with the Revised Foot Function Index and the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating system for the foot and ankle.

Of concern, "difficulty with prolonged standing" is not included in either of the clinical surveys, the researchers note in the Journal of Bone and Joint Surgery.

Furthermore, a substantial proportion of the clinical scales cover issues that were not highly rated by patients. Specifically, 38% of questions in the Revised Foot Function Index cover social issues and stiffness, while half of the 100 points in the AOFAS scale are given on footwear, motion, stability, callus, and alignment.

"Additional research and validation are needed to produce a clinically relevant outcome instrument that includes factors that are both important to the patient and useful for the clinician," Baumhauer et al recommend.

In an accompanying editorial, Patrick Ebeling (Twin Cities Orthopedics, Burnsville, Minnesota, USA) applauds the researchers for their work on identifying demographic factors that determine patient satisfaction.

"In addition, some work could, and should, be done to determine whether factors that foot and ankle surgeons traditionally have considered to be important may, in fact, capture factors identified by patients," he suggests, such as the use of walking aids as a proxy for stability.

"I expect that the best measurement tool, like the best surgical outcomes, will grow out of a joint effort between our patients and us," he concludes.

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