The Journal of Foot & Ankle Surgery 57 (2018) 149–154

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The Journal of Foot & Ankle Surgery

j o u r n a l h o m e p a g e : w w w. j f a s . o r g

Measuring Recovery After Ankle Fractures: A Systematic Review of

the Psychometric Properties of Scoring Systems
Reginald Ng, MBBS(Hons) 1, Nigel Broughton, FRCSEng, FRACS 2,3, Cylie Williams, BAppSc(Pod), PhD 4,5
1Medical Student, Peninsula Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston, VIC, Australia
2
Consultant Orthopaedic Surgeon and Director of Orthopaedic Research, Peninsula Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston,
Victoria, Australia
3Consultant Orthopaedic Surgeon and Director of Orthopaedic Research, Department of Surgery, Peninsula Health, Frankston, Victoria, Australia
4Allied Health Research Lead, Peninsula Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston, Victoria, Australia
5
Allied Health Research Lead, Allied Health, Peninsula Health, Frankston, Victoria, Australia

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 3 Recovery after ankle fractures places a considerable burden on patients both short and long term. Nu-
merous tools called patient-reported outcome measures (PROMs) have been developed to measure the
Keywords:
outcome of ankle fractures. They can assist clinicians to measure the effect, guide intervention, and assess
ankle
fracture the rate of recovery. We identified and evaluated the psychometric properties of PROMs used in the as-
patient-reported outcome measure sessment of ankle fractures. In a systematic search, we examined 4 databases from inception to December
psychometric 4, 2016. Search terms included ankle fracture, ankle pain, disability, gait, questionnaire, and PROMs. Ref-
erence lists were also examined. The inclusion criteria were English studies and adult populations. The
psychometric properties of the identified PROMs were examined, including internal consistency, test–
retest reliability, validity, floor–ceiling effects, and minimally important clinical differences. We identified
22 PROMs relating to ankle pain and disability. Only 5 were specifically used for ankle fractures. The 36-
item short-form health survey and short musculoskeletal functional assessment reported floor–ceiling
effects, and the lower extremity functional scale reported good responsiveness and content validity, al-
though these are not tools specifically related to ankle fractures. The ankle-fracture outcome of rehabilitation
measure (A-FORM) and the Olerud and Molander questionnaire were ankle fracture specific and as-
sessed for internal consistency and validity. Clinicians should use the most appropriate PROM to evaluate
patients’ recovery from ankle fractures. The A-FORM currently has the most appropriate evidence sup-
porting its use as a PROM for ankle fracture management and rehabilitation.
© 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.

Ankle fractures are relatively common and account for 9% of all frac-
ture presentations (1). The estimated incidence of ankle fractures has
been reported to be 122 per 100,000 person-years from Edinburgh
(2), 187 from Rochester, New York (3), and 147 from Geelong in Vic-
toria, Australia (4). This equates, for example, in Geelong, to 1 of every
700 adults sustaining an ankle fracture annually (4). The most com-
monly affected people are active young men due to high-energy trauma
(5) and older women due to low-energy trauma (6). The Australian
Institute of Health and Welfare’s National Hospital Morbidity Data-
base documented that >16,500 admissions for ankle fractures to
Financial Disclosure: None reported.
Conflict of Interest: C.W. provided statistical support and reported this informa-
tion with the authors who designed the A-FORM.
Address correspondence to: Reginald Ng, MBBS(Hons), Peninsula Health Clinical
School, Monash University Faculty of Medicine, Nursing and Health Sciences, P.O. Box
52, Frankston, VIC 3199, Australia.
E-mail address: reginaldngbr@gmail.com (R. Ng).
Australian hospitals occurred in 2013 to 2014 (7). Whether ankle frac-
tures are treated with a cast or operatively, this type of fracture
generally requires treatment for ≥6 weeks. The most recent Co-
chrane review supports rehabilitation beginning as soon as the fracture
has been appropriately treated (8). During the period of immobiliza-
tion and rehabilitation, a patient’s daily function is greatly impaired
(9). Returning to normal activities after treatment varies consider-
ably and can place a considerable burden on patients in terms of their
day to day activities (4), including their ability to return to work (10).
Complications can also occur during recovery, including infections (11),
posttraumatic osteoarthritis (12), and delayed union or nonunion
(13,14). Ankle fractures can result in chronic functional impairment
and mechanical instability (15) and can require long-term rehabili-
tation to reverse the effects of muscle atrophy (16).
Numerous tools have been developed to measure the outcomes of
health conditions from the patient’s perspective. Such tools are re-
ferred to as patient-reported outcome measures (PROMs). These allow

1067-2516/$ - see front matter © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2017.08.009
150 R. Ng et al. / The Journal of Foot & Ankle Surgery 57 (2018) 149–154

Table 1
Databases searched and search terms

Database Ankle Ankle Fracture* Pain* Quality of Life Walk* Range of Motion Joint Instability Questionnaire* Treatment Outcome or
Outcome Assessment

OVID Medline 8628 689 128,437 155,806 84,145 16,707 18,175 391,311 817,549
CINAHL 3741 847 54,807 69,291 15,422 19,082 6128 279,202 220,213
Embase 38,831 9984 374,176 368,981 62,626 34,076 9577 570,393 365,951
Cochrane Library 5105 255 93,082 45,702 5670 6150 754 55,980 135,263

* Denotes truncation for variations in search terms.

clinicians to quantify patients’ activities of daily living, pain, and other (OVID Medline, Embase, Cochrane Library, and CINAHL Plus) from inception to De-
functional outcomes (17), as prioritized by the patient. PROMs assist cember 4, 2016.

clinicians in documenting the outcomes of treatment and can be used

to determine the need for intervention. PROMs are typically condi-
tion specific, and many have been developed to assess foot and ankle
pathology, including foot and ankle instability (18), the effect of os-
teoarthritis of the ankle (19) and its treatment, and more general
outcomes of foot function (20). The aim of the present systematic
review was to identify the PROMs used to evaluate foot and ankle func-
tion after ankle fractures and to determine the quality of these
questionnaires according to their psychometric properties to guide cli-
nicians in the most appropriate tool for future use.
Materials and Methods
The present review was performed and reported in accordance with the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (21). The
population, intervention, comparison, and outcomes model was used (22) to develop
the search terms using the Boolean operators “AND” and “OR” to combine each domain.
Search terms relating to comparison interventions were not used and truncation (as-
terisk) was used for variations of search terms. The keyword search terms used to identify
the studies using PROMs or tools that elicited the patient’s view in the evaluation of
recovery after ankle fracture are listed in Table 1. Four electronic databases were searched
Search Strategy
The titles and abstracts of 2166 reports (Fig.) were screened by the 3 of us (R.N.,
N.B., C.W.) against the inclusion criteria listed in Table 2. Studies were included for full-
text review if 2 of us independently agreed on inclusion. Two of us (R.N., N.B.) reviewed
these studies; if the full text was not available or the report did not describe the psy-
chometric properties of an ankle fracture-specific PROM, the study was excluded. A
total of 59 full-text reports were reviewed against the inclusion criteria. Disagree-
ments were resolved by discussion among all 3 of us (R.N., N.B., C.W.). The reference
lists of the included studies were searched using the OVID Medline database to iden-
tify additional studies. If a PROM specific to ankle fracture had been discussed within
a study without the psychometric properties, the name of the PROM was searched using
OVID Medline to determine how the tool was developed. A forward search strategy was
also used to determine whether any studies had investigated the psychometric prop-
erties of each PROM after development. The review team was not kept unaware of the
authorship, date of publication, or journal of publication.
Data Extraction and Quality Appraisal
One investigator (R.N.) extracted the data relating to the descriptors and quality
assessment of the PROMs. A second investigator (C.W.) supported this extraction if clar-

Records identified through database searching

Embase 1974 (n = 876)
Ovid MEDLINE(R) 1946 with Daily Update (n =
Identification

711)
CINAHL Plus (n = 777)
Additional records identified
Cochrane library (n = 233) through other sources
Total (n=2597) (n = 0)

Records after duplicates removed

(n = 2166)
Screening

Records screened Records excluded based on

(n = 2166) title and abstract
(n = 2107)

Full-text articles assessed Full-text articles excluded,

for eligibility using criteria
Eligibility

(n = 59) (n = 37)

Studies included in Full-text articles excluded for

qualitative synthesis not including ankle fractures
(n = 22) (n = 17)
Included

Studies included in
quantitative synthesis
(n = 5)

Fig. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
 R. Ng et al. / The Journal of Foot & Ankle Surgery 57 (2018) 149–154 151

Table 2

Abbreviations: A-FORM, ankle-fracture outcome of rehabilitation measure; LEFS, lower extremity functional scale; MOS, Medical Outcomes Study; NR, not reported; O&M, Olerud and Molander; Ref., reference; SF-36,
Questions (n)
Inclusion and exclusion criteria

Criteria

15

11

53

20
Inclusion
Article reported in English and available as full text

Rating Scale
Study included a PROM questionnaire specifically used for ankle function
evaluation after ankle fracture
Main goal was to evaluate psychometric properties of a PROM questionnaire used
for foot function evaluation after ankle fracture

1*

1
Study used new data instead of data extracted from other research (e.g., systematic
reviews)

Clinical visit, weekly intervals

for 4 wk or until discharge
Clinical visit, 1 wk and 2 wk
Clinical visit and 1 wk after
Article included a criterion or norm-referenced test with a standardized
assessment procedure
Exclusion

Administration Point
Article not available in English
Study did not evaluate ankle fractures

after fracture
cast removal
Questionnaire included a skeletally immature population (children)
Article had no abstract available

Abbreviation: PROM, patient-reported outcome measure.

NR

NR

fracture (including ankle) or

Used within MOS of fractures,
ification were needed. If disagreement occurred during data extraction, the third

Knee/ thigh/ leg/ foot/ ankle

including ankle fractures

upper extremity fracture

Unilateral lower extremity
investigator (N.B.) supported this process.
The quality of the psychometric properties of each PROM was critically appraised using
the consensus-based standards for the selection of health measurement instruments
(COSMIN) tool (23). The COSMIN tool was developed as a standard method for evaluating
the use and psychometric properties of health measurement instruments. It evaluates the

Fracture Type
reliability, validity, and responsiveness of a tool to ensure it is the best instrument for its
designed purpose. The COSMIN tool guides the user to rate each methodologic property
as excellent (score of 3), good (score of 2), fair (score of 1), or poor (score of 0) using a de-

Ankle

Ankle
scriptive criteria rubric. The overall score per box is determined by the item with the lowest
score. Generalizability and interpretability are not used within the scoring but as ex-
tracted information to determine the study population and sampling.

36.8 (26.1 to 53.8)

49 (31.3 to 66.7)
Results

44 (NR)
Age (y)

We found 22 PROMS relating to ankle pain and disability reported

NR

NR
within the published data. However, only 5 had been used to assess pa-
tients with ankle fractures. Often, ankle fracture outcomes were measured
Study Population (Males, n; %)

458 (196; 43%) (n = 106 with

according to activity limitation rather than a PROM, such as the Clinical

107 (46; 43%) (n = 14 with

Demerit Points (24) or the Maryland Foot Score (25) or from perfor-
mance measures such as the walking speed or time required to climb a
set number of stairs (26). The 5 PROMs were different as they collected

36-item short-form health survey; SMFA, short musculoskeletal functional assessment.

ankle problem)
ankle fracture)
data specifically from the patient on how their ankle fracture had affect-
41 (30; 71%)

ed their work and emotional, financial, or physical health.

The 5 PROMs identified in our search were the 36-item short-
form health survey (SF-36), short musculoskeletal functional
NR
90

assessment (SMFA), ankle-fracture outcome of rehabilitation measure

psychometrically sound, and

(A-FORM), Olerud and Molander (O&M) questionnaire, and lower ex-

Develop a standardized health

condition-specific measure
brief; was also constructed

yielding reliable and valid

Develop and refine a PROM

tremity functional scale (LEFS). A summary of these 5 PROMs is

Evaluating symptoms after

clinical and research tool

without double-barreled
psychometric properties

Develop an English SMFA

appropriate for use as a

presented in Table 3, and the quality assessment of these 5 PROMs

status survey that is

Develop a self-report,

measurements and
for use in the MOS

using the COSMIN tool is provided in Table 4.

Data in parentheses are ranges, unless otherwise noted.
and examine its

comprehensive,
ankle fractures

A summary of the performance of the tools follows.

questions

Reliability
Aim

Only the A-FORM, SMFA, and LEFS reported the internal consis-
Descriptive data of 5 included studies

tency and reliability of the tools. The internal consistency, or ability

Questionnaire

for the test to measure the same idea, was excellent for the A-FORM
and good for the SMFA and LEFS. The reliability, or measure of how
A-FORM

* Summated rating scale.

well the tool repeatedly measured the same item, was good for the
SF-36

SMFA
O&M

LEFS

A-FORM, SMFA, and LEFS.

Van Son et al (30)
McPhail et al (28)

Binkley et al (31)
Olerud et al (27)

Validity
Ware et al (29)

No questionnaire provided definite information of criterion valid-

Table 3

ity because no current reference standard regarding ankle fracture

Ref.

PROMs has been reported. All the PROMs included in our review, except
152 R. Ng et al. / The Journal of Foot & Ankle Surgery 57 (2018) 149–154

Table 4
Score for reports rated using consensus-based standards for the selection of health measurement instruments checklist

Tool Measurement Properties Assessed IRT Used Score IRT A B C D E F G H I J Generalizability per Box

O&M scoring system (27) Interpretability No NA NA NA NA NA NA NA NA NA 0 0J

A-FORM (28) Content validity Yes +++ +++ ++ ++ +++ ++ NA NA NA ++ ++ +++ IRT
Internal consistency +++ A
Construct validity ++ B
Reliability ++ C
Responsiveness ++ D
Interpretability ++ E
++ I
++ J
SF-36 (29) Content validity No NA NA NA NA ++ NA NA NA NA ++ D
SMFA (32) Content validity No 0 ++ ++ NA +++ ++ ++ ++ NA ++ ++ 0 IRT
Construct validity ++ A
Reliability ++ B
Responsiveness +++ D
Hypotheses testing ++ E
Floor and ceiling effects ++ F
Interpretability ++ G
++ I
++ J
LEFS (31) Internal consistency No NA ++ ++ ++ +++ ++ NA NA NA +++ + ++ A
Reliability ++ B
Measurement error ++ C
Content validity +++ D
Structural validity ++ E
Responsiveness +++ I
Interpretability +J

Abbreviations: +++, excellent; ++, good; +, fair; 0, poor; A, internal consistency; A-FORM, ankle-fracture outcome of rehabilitation measure; B, reliability; C, measurement error;
D, content validity; E, structural validity; F, hypothesis testing; G, cross-cultural validity; H, criterion validity; I, responsiveness; IRT = item response theory; J, interpretability;
LEFS, lower extremity functional scale; NA, not available; O&M, Olerud and Molander; SF-36, 36-item short-form health survey; SMFA, short musculoskeletal functional assessment.

for the O&M questionnaire, provided details on content validity. The
SMFA scored well for content validity and construct validity; however,
its primary use was for upper and lower limb fractures. The LEFS also
scored well for content validity and construct validity but was used
in patients with any lower limb abnormality, including the thigh, knee,
leg, ankle, and foot. The A-FORM was the only tool designed specif-
ically for patients with ankle fractures. The O&M questionnaire provided
limited information on its development as an outcome measure. The
SF-36 reported content validity but had limited evaluation for pa-
tients with ankle fractures and was not developed specifically for such
patients. Thus, the rating of the PROM’s content validity and other psy-
chometric parameters was negative (32). Other validity measures are
listed in Table 4.
Responsiveness
The SF-36 and SMFA reported floor and ceiling effects; however,
these effects were not specific to ankle fractures. The SMFA was also
limited by ceiling effects (32). The LEFS reported no ceiling and floor
effects in the patient population. The LEFS also reported good sensi-
tivity to change over weeks using a prognosis rating, based on work
from Westaway et al (33), who proposed that experienced clinicians
could accurately predict the prognosis of patients (31). However, the
results also were not specific to ankle fractures. Information on known
floor and ceiling effects were presented graphically for the O&M ques-
tionnaire, although the patients with the lowest and highest possible
scores could not be distinguished from each other (34). Therefore, the
O&M questionnaire was rated as poor in terms of interpretability. In
the original description of the O&M questionnaire, no information was
given about floor and ceiling effects; however, comments were made
in the discussion section on the patient cohort where scores were low
or high. No tools reported the standardized response mean or minimal
clinically important difference in relation to ankle fracture recovery.
Use Within Clinical Practice
Limited information was provided on the administration time re-
quired for each of the tools, except for the SF-36, which was reported
as 5 to 10 minutes (35), and the LEFS, which was reported as <2 minutes
(31). The O&M questionnaire and A-FORM have 9 and 15 questions,
respectively, similar to the 11 questions in the SF-36. Hence, it can
be presumed that the administration time would be similar. The SMFA
has a substantially greater number of 53 questions indicating a longer
administration time. All the tools had been tested and developed as
paper-based questionnaires, with limited information given on elec-
tronic delivery or telephone administration.
Discussion
To the best of our knowledge, the present review is the first to eval-
uate the use of PROMs specifically related to ankle fracture by a
systematic review of the published data and to measure the PROMs
against the COSMIN tool.
The psychometric properties of a PROM determine its reliability,
reproducibility, and validity in its use in measuring a construct. A tool
with high-quality psychometric properties can obtain an objective mea-
surement, allowing data to be categorized and compared, and aid in
decisions regarding appropriate treatment. A move is occurring to
embed PROMs into all domains of clinical practice. Nationally funded
organizations such as PROMIS (36) in the United States and Health
and Social Care Information Centre (37) in the United Kingdom rou-
tinely develop PROMs specific to conditions to improve patient
outcomes. However, guidance from these organizations is lacking about
which PROMs to use after ankle fractures despite their considerable
burden. The present review of the current PROMs specific to ankle frac-
tures should prompt clinical researchers to use appropriate PROMs
for ankle fracture outcomes research.
 R. Ng et al. / The Journal of Foot & Ankle Surgery 57 (2018) 149–154
The O&M questionnaire was the most common tool cited within
many studies reporting the outcomes of ankle fractures. This tool has
previously been criticized for its lack of empirical evidence during de-
velopment (27) and its limited psychometric evaluation (38,39). It was
developed before the rigorous psychometric evaluation to which many
newer tools have been subjected, but no further investigation has been
made on any of these aspects. This systematic review highlighted the
number of methodologic concerns in its use that should dissuade the
clinician researcher from using it as a descriptor in future studies.
The A-FORM emerged as the only PROM that had been devel-
oped specifically for ankle fractures with acceptable psychometric
qualities. Despite this, the tool lacked further investigation perfor-
mance over a longer rehabilitation period, with data only reported for
≤16 weeks after fracture (28). The A-FORM appears relatively new and
requires more analyses alongside other PROMs. The SMFA also had
reported psychometric properties specific to ankle fractures and, like
the A-FORM, appears relatively new. The LEFS, formed in 1998, has
been translated into Portuguese (40), Persian (41), German (42), and,
most recently, Finnish (43) for other musculoskeletal injuries such as
hip or knee replacements. The LEFS also requires further testing for
longer periods, because it has been only used for testing ≤4 weeks after
a lower limb injury. Clinicians should also consider when the use of
duplicate tools to measure outcomes might or might not be re-
quired. A recent study of tibial fracture outcomes using the SMFA and
SF-36 showed that the scores on both PROMs were highly correlated
(44). Further investigation would be required to determine whether
the same is true for ankle fractures.
One limitation of the present systematic review was the small
number of questionnaires reported within studies, in addition to the
small number of studies that have used these tools. Future research
into ankle fracture rehabilitation should consider embedding the
A-FORM, LEFS, and/or SMFA to further develop an understanding of
how these tools perform in ongoing management.
Medical practitioners, surgeons, and other healthcare clinicians
should give preference to the use of the A-FORM, LEFS, or SMFA when
treating patients with ankle fractures over the other evaluated tools.
The method by which these tools were designed is most appropri-
ate, and their use has been evaluated with the best evidence for
measuring the daily effects of ankle fractures on activities of daily living.
This recommendation has not considered the ease of administration
or time required for scoring because limited information concerning
these issues has been previously reported.
In conclusion, our systematic review has shown that the A-FORM is
the most appropriate PROM in terms of psychometric properties and de-
velopment. We would encourage its use in monitoring improvements
during recovery and assessing the outcomes after ankle fractures.
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