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Impact of Comorbidities on the Measurement of Health in Patients with Ankle Osteoarthritis
Charles L. Saltzman, MD1; M. Bridget Zimmerman, PhD2; Michael O'Rourke, MD2; Thomas D. Brown, PhD2; Joseph A. Buckwalter, MD2; Richard Johnston, MD2
1 Department of Orthopaedics, University of Utah, 590 Wakara Drive, Salt Lake City, UT 84108. E-mail address: charles.saltzman@hsc.utah.edu
2 Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
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Note: The authors appreciate the thoughtful and critical review of the manuscript by Dr. Ingrid Nygaard, Dr. William Abdu, and Dr. David Felson.
In support of their research for or preparation of this manuscript, one or more of the authors received award P50 AR48939 from the National Institutes of Health, Specialized Center of Research in Osteoarthritis. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Nov 01;88(11):2366-2372. doi: 10.2106/JBJS.F.00295
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Background: Investigators seeking to understand the impact of musculoskeletal disorders commonly use validated outcome instruments to assess the effect of diseases on physical function and quality of life. However, the influence of concomitant systemic or musculoskeletal comorbidities on these scores has not been widely considered in orthopaedic research. The purpose of this study was to determine how morbidity unrelated to the ankle influences the perception of physical function and pain by patients with ankle osteoarthritis.

Methods: Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, Ankle Osteoarthritis Scale (AOS) pain scale scores, demographic data, and systemic and musculoskeletal comorbidities were determined prospectively for 195 patients with ankle osteoarthritis and ninety-five age and gender-matched controls. The effect of systemic and musculoskeletal comorbidities on each of the scores was determined.

Results: On the average, patients with ankle osteoarthritis had a relatively normal MCS score (47 ± 13 points) and a markedly diminished PCS score (32 ± 8 points). Both of these scores averaged 50 ± 9 points in the control group. The AOS pain score averaged 61 ± 23 points in the group with ankle osteoarthritis, whereas it averaged 10 ± 15 points in the control group. We found the perception of ankle pain by patients with ankle osteoarthritis to be significantly and linearly associated with the number of other musculoskeletal problems (not related to the foot or ankle).

Conclusions: The degree of physical impairment associated with ankle osteoarthritis, as measured with the SF-36, is equivalent to that reported to be associated with severely disabling medical problems including end-stage kidney disease and congestive heart failure. The perception of ankle health status as measured with a validated, patient-oriented, anatomically specific instrument is influenced by the patients' perception of their overall musculoskeletal comorbidity status. The authors of clinical studies using these instruments should adjust for concomitant musculoskeletal disease.

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    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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