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Kroin et al
paradigm shift that should ideally include an objective clinical assessment of both function and patient-perceived outcome expectations.
The implied rationale for subjecting this highly comorbid patient population to the potential risks associated with
operative correction of the acquired deformity suggests that
successful operative correction of deformity will improve
the patients' ability to ambulate in the community without
the need for cumbersome custom orthotic devices, decrease
the pain associated with complex deformities, and somehow reverse the perceived impairment.7,9,10,12,13,15
We have recently demonstrated that correction of
acquired midtarsal Charcot foot deformity has the potential
to successfully achieve the traditional goals of eradication
of infection and limb salvage, as well as eliminate the need
for cumbersome accommodative custom orthotic devices.
This allows patients to successfully achieve the functional
goal of ambulation in the community with noncustom commercially available "diabetic shoes."10 The goal of this
companion investigation was to determine whether successful correction of deformity would also be associated with a
corresponding improvement in patient-reported outcomes
using modern patient survey methodology.

Methods
Following Institutional Review Board approval, 25 consecutive patients undergoing operative correction of midtarsal
diabetes-associated Charcot foot deformity completed the
Short Musculoskeletal Assessment Examination (SMFA)
prior to surgery. All patients had both clinically and radiographically nonplantigrade deformity at the midtarsal level
with no evidence of disruption of the tibiotalar joint.1,2,9,11,17
There were 16 men and 9 women. The average age of the
patients was 59.5 (range, 35.1-73.2) years. Body mass index
was 37.4 (range, 25.8-50.2), and hemoglobin A1C was 7.5%
(range, 5.3%-10.1%).5
The SMFA was chosen because of its previously reported
consistency with comparable instruments in similar patient
populations.2,5,6,8,11 We have also previously demonstrated
that the reported negative impact on quality of life in this
specific patient population appears similar in magnitude to
previous reports.3,5,8,11 The SMFA is a 2-part, 46-item, selfreported health status questionnaire. Most patients complete the questionnaire in approximately 10 minutes,
avoiding sampling fatigue. It consists of 2 indices (dysfunction index and bother index) and 4 subscales (daily activities, emotional status, arm and hand function, and mobility).
The dysfunction index has 34 items for assessment of the
patients' perceptions of their functional performance. For
each question, the choices are not at all difficult (1 point), a
little difficult (2 points), moderately difficult (3 points), very
difficult (4 points), and unable to do (5 points). The bother
index includes 12 questions that allow patients to assess

how much they are bothered by problems in broad functional areas. For each question, the choices are not at all
bothered (1 point), a little bothered (2 points), moderately
bothered (3 points), very bothered (4 points), and extremely
bothered (5 points).16
Surgery included percutaneous Achilles tendon lengthening, excision of a wedge of bone at the apex of the deformity, resection of osteomyelitis when present, and
maintenance of the correction with a 3-level static circular
external fixator for 12 weeks.7,9,10
Twenty-four of 25 patients completed the SMFA at 1
year following surgery. One patient died from unrelated
medical comorbidities during the follow-up period.
Functional outcomes were rated using the historic metrics
of resolution of infection, successful limb salvage, and the
ability to walk without encumbering orthoses. Patients
were rated as excellent if they were free from ulcer and
infection and able to walk outdoors with commercially
available therapeutic footwear. Patients were rated as good
if they fulfilled the criteria for excellent but required a
short ankle foot orthosis or custom shoe modification.
Patients were rated as poor if they had residual wounds, a
partial- or whole-foot amputation, or required a standard
ankle foot orthosis or Charcot restraint orthotic walker
(CROW).10

Statistical Analysis
The SMFA survey raw scores were calculated based on the
published scoring criteria. The responses to the items were
summed to establish the scores on the dysfunction index
and the bother index. The scores were then standardized to
range from 0 to 100 with the use of the scoring formula,
with poorer function indicated by higher scores.16
A paired t test was used to estimate the mean change in
each standardized SMFA index from baseline to follow-up.
Because of the small sample sizes and some nonnormally
distributed change scores, all conclusions were confirmed
using an exact version of the nonparametric Wilcoxon
signed rank test.

Results
Eighteen of the 24 patients (75%) achieved an excellent
clinical outcome, with 3 patients (12.5%) achieving a good
and 3 (12.5%) achieving a poor functional result.
On average, there was an approximate 11.5-point (95%
confidence interval [CI]: -19.7 to −3.2) decrease in the
SMFA standardized functional index (P = .01). Similarly,
there was an approximate 12.4-point (95% CI: -22.5 to
−2.3) decrease in the standardized bother index (P = .02). On
average, there was a 19.6-point (95% CI: -30.5 to −8.6)
decrease in the standardized daily activity index (P = .002).
Lastly, there was a 14.7-point (95% CI: -24.1 to −5.3)



Table of Contents for the Digital Edition of Foot & Ankle International - July 2018

Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
Foot & Ankle International - July 2018 - viii
Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
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Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
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Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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