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Age and Sex Differences Between Patient and Physician-Derived Outcome Measures in the Foot and Ankle
Judith F. Baumhauer, MD, MPH1; Scott McIntosh, PhD1; Glenn Rechtine, MD2
1 Department of Orthopaedic Surgery and Rehabilitation, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue Box 665, Rochester, NY 14620. E-mail address for J.F. Baumhauer: Judy_Baumhauer@urmc.rochester.edu
2 Bay Pines VA Healthcare System, 10000 Bay Pines Boulevard, Mail code 11-B, Bay Pines, FL 33744
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A commentary by Patrick B. Ebeling, MD, is linked to the online version of this article at jbjs.org.

Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Feb 06;95(3):209-214. doi: 10.2106/JBJS.K.01467
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Traditionally, physicians have identified which outcome factors are important to measure in order to determine the success or failure of treatment without any input from patients. The purpose of the present study was to ascertain the five outcome factors that are most important to the patient and the impact that age and sex have on these factors. These five most important patient-derived outcome factors were then compared with factors within two of the most commonly used outcome instruments for the foot and ankle.


Informant interviews, pre-testing, consistency analysis, and pilot testing led to the construction of a twenty-item survey of outcome factors that patients identified as being important in the treatment of their foot or ankle problem. Subjects selected the top five factors and rank ordered them from 1 to 5 (with 1 representing extreme importance and 5 representing least importance). One thousand computer simulations identified the top five factors, and these were subsequently stratified for sex and age. Wilcoxon rank-sum and Benjamini-Hochberg tests were used to compare the data between groups.


The survey was completed by 783 subjects. The five most important factors were limited walking (p < 0.05), activity-related pain (p < 0.05), constant pain (p < 0.05), difficulty with prolonged standing (p = 0.754), and inability to do one’s job or housework (p = 0.995). Shoe-related issues and foot and ankle weakness were significantly different between the sexes. Constant pain, inability to play sports, inability to participate in a job or housework, and recurrent foot or ankle skin sores or infections were significantly different between age groups. Between 38% and 50% of the outcome points found on two commonly used foot and ankle instruments included factors not of primary importance to the patient.


There are sex and age-related differences regarding outcome factors following the treatment of disorders affecting the foot and ankle. As many as 50% of the factors in currently used foot and ankle outcome instruments are not of primary importance to patients.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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