Validity of the Arabic version of AAOS-foot and ankle outcomes questionnaire in patients with traumatic foot and ankle injuries

Abstract

BACKGROUND

Arabic-speaking patients are underrepresented in orthopedic clinical studies, particularly in foot and ankle trauma research. The lack of validated Arabic language tools hinders their inclusion, creating a need for culturally and linguistically adapted instruments. The American Academy of Orthopedic Surgeons Foot and Ankle Outcomes Questionnaire (AAOS-FAOQ) is a widely used tool but has not been adapted for Arabic-speaking patients.

AIM

To translate, cross-culturally adapt, and validate the AAOS-FAOQ for Arabic-speaking patients with traumatic foot and ankle injuries.

METHODS

The cross-cultural adaptation followed established guidelines, involving forward and backward translations, expert review, and pre-testing. The final Arabic version was administered alongside the Arabic Short-Form 36 (SF-36) to 100 patients for validity testing. Reliability was assessed through test-retest methods with 20 patients completing the questionnaire twice within 48 hours. Pearson correlation coefficients measured convergent and divergent validity with SF-36 subscales, while Cronbach's alpha and intraclass correlation coefficients (ICC) determined internal consistency and reliability.

RESULTS

Out of 100 patients, 92 completed the first set of questionnaires. The Arabic AAOS-FAOQ showed strong correlations with the SF-36 subscales, particularly in physical function and bodily pain (r > 0.6). Test-retest reliability was robust, with ICCs of 0.69 and 0.66 for the Global Foot and Ankle Scale and Shoe Comfort Scale, respectively. Cronbach's alpha for internal consistency ranged from 0.7 to 0.9.

CONCLUSION

The Arabic version of the AAOS-FAOQ demonstrated validity and reliability for use in Arabic-speaking patients with traumatic foot and ankle injuries. This adaptation will enhance the inclusion of this population in orthopedic clinical studies, improving the generalizability of research findings and patient care.

Key Words: Arabic version; American Academy of Orthopedic; Foot and Ankle Outcomes; Orthopedic; Trauma

Core Tip: The Arabic version of the American Academy of Orthopedic Surgeons Foot and Ankle Outcomes Questionnaire has been successfully translated, cross-culturally adapted, and validated. It demonstrated strong validity and reliability for Arabic-speaking patients with traumatic foot and ankle injuries. This adaptation addresses the gap in outcome measures for this population, facilitating their inclusion in clinical studies and improving the generalizability of research findings in orthopedic care.

INTRODUCTION

This study will be conducted at King Fahad Hospital of the University in Al Khobar using the hospital’s electronic record system, the OR database. Recent data from the Arab world have highlighted the significant representation of Arabic-speaking populations across the region. In particular, the Arab world encompasses over 420 million people, with Arabic as the primary language spoken in countries throughout the Middle East and North Africa (MENA) region. As this population continues to grow and diversify, there is an increasing need for healthcare tools and resources that are culturally and linguistically adapted to meet the specific needs of Arabic-speaking patients[1].

In the field of orthopedics, the representation of Arabic-speaking patients in clinical outcome studies is crucial to ensure that study populations reflect the diverse demographics of the MENA region. However, much like the underrepresentation of Hispanics in clinical trials in the United States, Arabic-speaking patients are often underrepresented in orthopedic clinical trials[2]. This underrepresentation can lead to a lack of generalizability of study results and raises concerns about potential systematic biases within the orthopedic literature.

One significant barrier to the inclusion of Arabic-speaking patients in clinical trials is the lack of validated outcome measures available in the Arabic language. Many widely used orthopedic outcome instruments have been established in English-speaking countries, and their translation, cross-cultural adaptation, and validation into Arabic are often lacking[3]. Recent efforts have been made to translate and adapt general health-related quality of life measures into Arabic, such as the Short-Form 36 (SF-36) and other musculoskeletal assessment tools[4]. However, there remains a scarcity of well-designed cross-cultural adaptations and validations of foot and ankle-specific scoring systems for Arabic-speaking patients with traumatic foot and ankle injuries[5].

The American Academy of Orthopedic Surgeons Foot and Ankle Outcomes Questionnaire (AAOS-FAOQ) will be translated, cross-culturally adapted, and validated for Arabic-speaking patients with severe foot and ankle injuries in order to close this gap. The AAOS-FAOQ is a widely recognized and validated instrument in the United States, with previous validations in various languages and populations. The AAOS Foot and Ankle Questionnaire is a robust 25-item patient-reported outcome measure meticulously designed to evaluate foot and ankle-related disability across critical domains, including pain, function, stiffness, swelling, and shoe comfort. Grounded in the comprehensive biopsychosocial model, it captures the intricate interplay of biological, psychological, and social factors influencing health outcomes. By prioritizing patient perspectives, this instrument delivers an unparalleled, holistic assessment of foot and ankle conditions, thereby enhancing the precision and effectiveness of clinical evaluations[6]. To the best of our knowledge, this instrument has never been translated into Arabic, cross-culturally adapted, and validated for use with Arabic-speaking patients who have suffered catastrophic foot and ankle injuries. We predict that in this patient population, the Arabic version of the AAOS-FAOQ will show sufficient test-retest reliability and correlate with the SF-36v2[7].

MATERIALS AND METHODS

In our study, we employed two validated patient-reported outcome measures to assess patient health status.

AAOS-FAOQ

This 25-item instrument, developed by the American Academy of Orthopedic Surgeons, is designed to evaluate foot and ankle-specific disability. It encompasses domains such as pain, function, stiffness, swelling, and shoe comfort. Responses are scored on a scale, with higher scores indicating better foot function.

SF-36 health survey

The SF-36 is a comprehensive 36-item questionnaire assessing overall health-related quality of life across eight sections: Physical functioning, role limitations due to physical health problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health (MH). Each domain is scored separately, providing a detailed profile of the patient's health status.

Cross-cultural adaptation

The cross-cultural adaptation of the Arabic version of the AAOS-FAOQ was meticulously executed in accordance with established guidelines[8,9]. A specialized translation committee was constituted, comprising two native Arabic speakers proficient in English, two native English speakers proficient in Arabic, and a linguistic expert who provided oversight throughout the translation process, arbitrating any discrepancies that arose. The initial forward translation was conducted by two individuals: A Foot and Ankle Orthopedic surgeon and a medically untrained translator unfamiliar with the AAOS-FAOQ. This yielded two preliminary Arabic translations, T1 and T2. These versions were synthesized into a unified translation (T12) through consensus among the translators and the linguistic expert, ensuring conceptual and cultural equivalence. The T12 version was then subjected to back-translation into English by two independent translators, resulting in back-translated versions BT1 and BT2. A thorough review of all versions by the committee, with deliberation on any modifications, culminated in a pre-final Arabic version. This pre-final version underwent preliminary testing with a random sample of 10 patients from the outpatient clinic, who were asked to complete the questionnaire and report any difficulties in comprehension. As no significant issues were identified, the final Arabic version of the AAOS-FAOQ was subsequently disseminated for validation.

Patient population

Following the Institutional Review Board authorization from of Imam Abdulrahman bin Faisal University (IRB-2024-01-026), a prospective patient recruitment was undertaken. Patients presenting to the Foot and Ankle Clinic at King Fahad Hospital of the University, Al Khobar, between January and August 2024 were approached consecutively. Eligibility criteria included patients aged 18 years or older, diagnosed with foot or ankle disorders, native Arabic speakers, and individuals raised in one of the Arabian Gulf countries to ensure cultural alignment. Exclusion criteria encompassed patients younger than 18 years, those with lower extremity conditions other than foot or ankle traumatic injuries that could potentially impact functional outcomes, non-native Arabic speakers, and individuals not raised in the Arabian Gulf. Informed consent was obtained from all participants, who were then provided with either a printed or digital version of the Arabic AAOS-FAOQ alongside a validated Arabic version of the SF-36 questionnaire[10]. The questionnaires were completed in the waiting area, and any forms with more than one unanswered item were excluded from analysis. Patient demographics and clinical diagnoses were systematically documented.

Convergent and divergent validity

Construct validity was rigorously assessed by comparing the Arabic AAOS-FAOQ against the pre-validated SF-36 instrument, both of which were administered concurrently to each participant[10]. Convergent and divergent validity were evaluated by calculating Pearson’s correlation coefficients between the subscales of the Arabic AAOS-FAOQ and corresponding components of the SF-36. Correlations were categorized as weak (coefficient < 0.4), moderate (0.4 ≤ coefficient ≤ 0.7), or strong (coefficient > 0.7). Convergent validity was specifically examined through correlations with the physical function and physical component summary (PCS) subscales of the SF-36, as they measure analogous constructs. Divergent validity was assessed by correlating the MH and mental component summary (MCS) subscales, which are anticipated to represent distinct constructs.

Internal consistency

To assess the internal consistency of the Arabic AAOS-FAOQ, Cronbach’s alpha coefficients were calculated for each subscale. An alpha value below 0.5 was deemed unacceptable, values exceeding 0.7 were considered acceptable, values above 0.8 were regarded as good, and values above 0.9 were classified as excellent (Bland & Altman, 1997)[11]. The alpha coefficients were also employed to compute the standard error of measurement for the Arabic AAOS-FAOQ at a 95% confidence interval.

Test-retest reliability

Test-retest reliability was examined in a randomly selected subset of 20 participants who completed the Arabic AAOS-FAOQ on two separate occasions, with a 48-hour interval between administrations. Participants in this subset were presumed to have remained clinically and functionally stable during this period. Each subscale of the AAOS-FAOQ was analyzed independently. Reliability was quantified using intraclass correlation coefficients, and the minimal detectable change was also determined.

Statistical analysis

The SF-36v2 scores were calculated using licensed software, while the AAOS-FAOQ scores were calculated using the AAOS-provided worksheet. Statistical analyses was conducted utilizing IBM SPSS Statistics (version 20). The homogeneity of variance and the normality of outcome scale distributions were assessed using the Shapiro-Wilk test. Cronbach's alpha coefficients were used to evaluate the internal consistency of the final Arabic version of the AAOS-FAOQ, and correlation methods were used to study test-retest reliability. Using Pearson correlation coefficients, the relationship between SF-36v2 scales and AAOS-FAOQ scores was examined in order to assess validity. In all studies, a P-value of less than 0.05 was regarded as indicating statistical significance.

RESULTS

Patients

100 Arabic-speaking patients, 43 of whom were female and 57 of whom were male, gave their agreement to take part in the study. Traumatic injuries were found in 61 of these instances. The participants were between the ages of 18 and 85, with a mean age of 39.7 years (SD = 16.75). Thirty patients in the entire sample had nonoperative care, while seventy individuals had surgery. For nonoperative cases, the average follow-up time after surgery or injury was 4.02 months (SD ± 4.65). Twelve tibial pilon/plafond fractures, four ruptured Achilles tendon, twenty-five ankle fractures, five talus fractures, nine calcaneus fractures, and six midfoot fractures were among the injuries. Twelve of the 61 traumatic injury patients needed treatment for open fractures, while 49 of them had closed injuries. The study population's descriptive data are shown in Table 1.

Table 1 Descriptive statistics for the study sample, n (%).

All	N = 105
Age	39.7 years (range 18-85)
Gender
Male	56 (53.3)
Female	49 (46.6)
Nationality
Saudi	92 (87.6)
Egypt	5 (4.76)
Kuwait	3 (2.8)
Yemen	2 (1.9)
Education level
Primary	10 (9.52)
Secondary	13 (12.4)
High school	38 (36.2)
Bachelor	42 (40.0)
Master degree	2 (1.90)
Diagnosis
Degenerative diseases	25 (23.8)
Traumatic	61 (58.09)
Acquired deformity	11 (10.4)
Congenital	8 (7.6)
Traumatic cases
Pilon fracture	12 (19.6)
Achilles tendon rupture	4 (6.55)
Ankle fractures	25 (40.9)
Talus fractures	5 (8.19)
Calcaneus fractures	9 (14.75)
Midfoot fractures	6 (9.83)

Categorical data were summarized using counts and percentages. Age was summarized using the mean ± SD.

Arabic AAOS-FAOQ and Arabic SF-36

During their clinic visit, 92 out of the 100 patients who were enrolled filled out and submitted the first set of questionnaires (Arabic SF-36 and Arabic AAOS-FAOQ). The validity analysis made use of these answers. The Shapiro-Wilk test verified that the Global Foot and Ankle Scale of the AAOS-FAOQ and all SF-36 subscales had a normal distribution and homogeneity of variance. These scales were then subjected to parametric correlations. On the other hand, nonparametric techniques were necessary because the Shoe Comfort Scale of the AAOS-FAOQ did not show a normal distribution. The PCS and MCS scores, as well as all eight SF-36 subscales, exhibited statistically significant relationships with the Global Foot and Ankle Scale (Table 2). ≥ 0.6 strong correlations.

Table 2 Correlation of the Arabic American Academy of Orthopedic Surgeons Foot and Ankle Outcomes Questionnaire with the Short-Form 36.

SF-36 subscale	PF	RP	BP	GH	VT	SF	RE	MH	PCS	MCS
Global foot and ankle scale
Pearson correlation	0.617	0.610	0.733	0.337	0.455	0.649	0.508	0.525	0.638	0.563
P value	< 0.0001	< 0.0001	< 0.0001	0.005	< 0.0001	< 0.0001	< 0.0001	< 0.0001	< 0.0001	< 0.0001
Shoe Comfort Scale
Spearman rho	0.392	0.317	0.389	0.221	0.307	0.395	0.288	0.301	0.344	0.341
P value	< 0.0001	0.006	< 0.0001	0.124	0.005	< 0.0001	0.008	0.006	0.002	0.002

BP: Bodily pain; GH: General health; MH: Mental health; PF: Physical function; RE: Role emotional; RP: Role physical; SF: Social functioning; VT: Vitality; PCS: Physical component summary; MCS: Mental component summary; SF-36: Short-Form 36.

Test re-test reliability

Test-retest reliability was evaluated using the second set of questionnaires, which were completed by 20 patients in total. With coefficients of 0.69 and 0.66, respectively, the AAOS-FAOQ's Global Foot and Ankle Scale and Shoe Comfort Scale demonstrated suitable test-retest reliability.

DISCUSSION

As the number of Arabic-speaking people worldwide rises, particularly in regions with sizable immigrant populations, it is crucial to include these individuals in clinical research to guarantee that study findings represent a diverse patient population. However, language challenges and the absence of validated Arabic translations of patient-reported outcome measures frequently make it very challenging to include Arabic-speaking patients in clinical trials. Applying an outcome measure in a different language is known to necessitate not just an accurate translation but also a thorough cultural adaptation and validation process tailored to the target group[1,2]. To date, there has been no Arabic translation, cross-cultural adaption, or validation of the AAOS-FAOQ in Arabic-speaking patients with traumatic foot and ankle injuries, despite the fact that it is a commonly used and validated scoring system in English-speaking populations[6]. In individuals with such injuries, our study shows a substantial association between the Arabic SF-36 and the Arabic form of the AAOS-FAOQ. Strong test-retest reliability was also demonstrated by the Arabic AAOS-FAOQ, confirming its usage as a trustworthy outcome measure in clinical research including patients who speak Arabic.

The Arabic AAOS-FAOQ also showed strong test-retest reliability, supporting its use as a reliable outcome measure in clinical studies with Arabic-speaking patients. Among our study's many advantages are the thorough cross-cultural adaption procedure and the close relationship with the SF-36, a reliable indicator of overall health-related quality of life. Additionally, the Arabic AAOS-FAOQ showed good test-retest reliability over a minimum of 48 hours, which minimizes bias from patient memory and possible carryover effects[12]. However, the study also has limitations. While our validation process showed strong psychometric properties, we did not assess other important validation measures, such as the ability to detect change, minimum detectable difference, and minimum clinically important difference. Additionally, our study focused solely on Arabic-speaking patients with traumatic foot and ankle injuries, limiting the generalizability of our findings to other Arabic-speaking patient populations with different conditions.

Our findings are consistent with previous studies that validated the AAOS-FAOQ in other languages. For instance, Johanson et al[6] reported a validation of the English version of the AAOS-FAOQ in 70 patients with foot and ankle problems, demonstrating a correlation of 0.65 between the Global Foot and Ankle Scale and the SF-36. Their study reported test–retest reliability of 0.79 for the Global Foot and Ankle Scale when retesting was conducted within 24 hours. In comparison, our study used a longer interval between the first test and the retest, which may explain the slightly lower test–retest reliability we observed. Similarly, Kim et al[13] validated a Korean version of the AAOS-FAOQ and reported exceptionally high test–retest reliability, but their shorter retest interval may have influenced these results. The response rate for the first set of questionnaires was high, with 85 of 100 patients participating. However, only 65 patients returned the second set of questionnaires, which may introduce some bias into our findings. Despite this, we found no significant differences between responders and non-responders regarding demographic characteristics and initial AAOS-FAOQ scores, suggesting that our results are still robust. Nonetheless, it is important to acknowledge the potential challenges of data collection in this population, including cultural, educational, linguistic, and social barriers.

In our study, we acknowledge several limitations and potential biases that may influence the interpretation and generalizability of our findings. The relatively small sample size (n = 100) may limit the statistical power of our analyses, increasing the risk of Type II errors and reducing the precision of our estimates. A larger sample would enhance the robustness and generalizability of our results. Additionally, the mean follow-up duration of 4.02 months may not capture the long-term effects of traumatic foot and ankle injuries. Extended follow-up periods are necessary to assess the durability of treatment outcomes and the potential for late-onset complications Addressing these limitations and biases in future research is essential to enhance the validity and applicability of findings. Implementing strategies such as increasing sample size, extending follow-up periods, ensuring random selection, standardizing measurement tools, and maintaining consistent treatment protocols can help mitigate these issues.

CONCLUSION

In conclusion, we have successfully translated, cross-culturally adapted, and validated the AAOS-FAOQ for use in Arabic-speaking patients with traumatic foot and ankle injuries. The Arabic version of the AAOS-FAOQ has demonstrated to be a valid and reliable instrument in this patient population. Our findings align well with similar studies in other languages, supporting the use of this outcome measure in clinical studies involving Arabic-speaking patients. This adaptation of the AAOS-FAOQ will help ensure that Arabic-speaking patients are appropriately represented in clinical research within the field of foot and ankle trauma, ultimately leading to better-informed clinical decisions and improved patient care.

ACKNOWLEDGEMENTS

We would like to thank Loli Alomari for her outstanding support in doing the analysis and design the tables.