title: Minimal Clinically Important Differences for American Orthopaedic Foot & Ankle Society Score in Hallux Valgus Surgery.
abstract: BACKGROUND
  The American Orthopaedic Foot & Ankle Society (AOFAS) score is one of the most common and adapted outcome scales in hallux valgus surgery. However, AOFAS is predominantly physician based and not patient based. Although it may be straightforward to derive statistical significance, it may not equate to the true subjective benefit of the patient's experience. There is a paucity of literature defining MCID for AOFAS in hallux valgus surgery although it could have a great impact on the accuracy of analyzing surgical outcomes. Hence, the primary aim of this study was to define the Minimal Clinically Important Difference (MCID) for the AOFAS score in these patients, and the secondary aim was to correlate patients' demographics to the MCID.
  
  
  METHODS
  We conducted a retrospective cross-sectional study. A total of 446 patients were reviewed preoperatively and followed up for 2 years. An anchor question was asked 2 years postoperation: "How would you rate the overall results of your treatment for your foot and ankle condition?" (excellent, very good, good, fair, poor, terrible). The MCID was derived using 4 methods, 3 from an anchor-based approach and 1 from a distribution-based approach. Anchor-based approaches were (1) mean difference in 2-year AOFAS scores of patients who answered "good" versus "fair" based on the anchor question; (2) mean change of AOFAS score preoperatively and at 2-year follow-up in patients who answered good; (3) receiver operating characteristic (ROC) curves method, where the area under the curve (AUC) represented the likelihood that the scoring system would accurately discriminate these 2 groups of patients. The distribution-based approach used to calculate MCID was the effect size method. There were 405 (90.8%) females and 41 (9.2%) males. Mean age was 51.2 (standard deviation [SD] = 13) years, mean preoperative BMI was 24.2 (SD = 4.1).
  
  
  RESULTS
  Mean preoperative AOFAS score was 55.6 (SD = 16.8), with significant improvement to 85.7 (SD = 14.4) in 2 years ( P value < .001). There were no statistical differences between demographics or preoperative AOFAS scores of patients with good versus fair satisfaction levels. At 2 years, patients who had good satisfaction had higher AOFAS scores than fair satisfaction (83.9 vs 78.1, P < .001) and higher mean change (30.2 vs 22.3, P = .015). Mean change in AOFAS score in patients with good satisfaction was 30.2 (SD = 19.8). Mean difference in good versus fair satisfaction was 7.9. Using ROC analysis, the cut-off point is 29.0, with an area under the curve (AUC) of 0.62. Effect size method derived an MCID of 8.4 with a moderate effect size of 0.5. Multiple linear regression demonstrated increasing age (β = -0.129, CI = -0.245, -0.013, P = .030) and higher preoperative AOFAS score (β = -0.874, CI = -0.644, -0.081, P < .001) to significantly decrease the amount of change in the AOFAS score.
  
  
  CONCLUSIONS
  The MCID of AOFAS score in hallux valgus surgery was 7.9 to 30.2. The MCID can ensure clinical improvement from a patient's perspective and also aid in interpreting results from clinical trials and other studies.
  
  
  METHODS
  Level III, retrospective comparative series.
authors.affiliation: 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
authors.forename: Hiok Yang
authors.initials: HY
authors.lastname: Chan
authors.affiliation: 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
authors.forename: Jerry Yongqiang
authors.initials: JY
authors.lastname: Chen
authors.affiliation: 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
authors.forename: Suraya
authors.initials: S
authors.lastname: Zainul-Abidin
authors.affiliation: 2 Health Services and Biostatistics Unit, Department of Research, Singapore General Hospital, Singapore.
authors.forename: Hao
authors.initials: H
authors.lastname: Ying
authors.affiliation: 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
authors.forename: Kevin
authors.initials: K
authors.lastname: Koo
authors.affiliation: 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
authors.forename: Inderjeet Singh
authors.initials: IS
authors.lastname: Rikhraj
mesh_terms: D000842:Ankle / Q000502:physiology*; D003430:Cross-Sectional Studies; D006215:Hallux Valgus / Q000601:surgery*; D006801:Humans; D008683:Metatarsophalangeal Joint / Q000502:physiology / Q000601:surgery*; D000071081:Minimal Clinically Important Difference; D009985:Orthopedics; D010147:Pain Measurement / Q000592:standards; D020127:Recovery of Function; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014481:United States
keywords: AOFAS; MCID; ROC curve; clinical outcomes; effect size; hallux valgus; mean change; mean difference