The Short Musculoskeletal Functional Assessment (SMFA) score and surgical outcomes in Amman, Jordan
description
Transcript of The Short Musculoskeletal Functional Assessment (SMFA) score and surgical outcomes in Amman, Jordan
The Short Musculoskeletal Functional Assessment
(SMFA) score and surgical outcomes in Amman, Jordan
Rasheed M. Fakhri, Nancy Foote, Carrie Teicher
Médecins Sans Frontières (MSF)/Doctors Without Borders, Amman, Jordan (RM Fakhri MD FICMS, NL Foote MD MPA); Epicentre, New York, New York (CL Teicher MD MPH)
Acknowledgements
We would like to thank all those in the field and the Desk
who contributed to this project. We would also like to
thank Patricia Kahn (MSF-USA), Emmanuel Baron
(Epicentre, Paris, France) and April Shu (Harvard School
of Public Health) for contributions to this presentation.
Introduction Surgical reconstruction of lower limb injuries in war-
wounded civilians produces a range of functional outcomes
where prognosis is potentially predictable using a scoring
system.
The MSF program in Amman, Jordan is a tertiary care
hospital and rehabilitation center that provides specialized
reconstructive surgical care to war-wounded civilians in the
region.
The short musculoskeletal functional assessment score
(SMFA) provides a method for quantitatively assessing
functional status following orthopedic trauma. This self-
reported health-status questionnaire is used for assessing
the impact of treatment in patients with musculoskeletal
injury. The SMFA has two parts: the Dysfunction Index,
which detects elements of functional status, and the
Bothersome Index, which allows patients to evaluate how
bothered they are by functional challenges.
In June 2010 the Amman team established SMFA as the
standard for measuring patients’ functional status. The
objective of this retrospective study is to evaluate whether
the Admission Dysfunction Index (ADI), as determined by
SMFA scores, is a useful prognostic tool for patients with
chronic war injuries treated in the Amman facility.
Methodology
All patients with lower limb injuries requiring
reconstruction were enrolled in the study (n=84).
Patients were excluded if non-standard surgical
procedures were required. Each patient’s SMFA was
assessed at admission, at discharge from Amman and
during follow-up in home country. The last follow-up
questionnaire was in April 2012.
In the analysis we compared patients with infected
(infections found at surgery) versus non-infected
injuries as well as with both high and low ADI, using
Stata 12.
Limitations of this data relate to the small sample size,
translation of the SMFA questionnaire into Arabic and
to the data tool’s reliance on patient self-reporting.
Results Among infected patients, higher ADI correlated with more
surgeries and longer hospital stay (see tables). Infected
patients with ADI>50 required an average of 2.7 surgeries
while those with ADI<50, averaged 1.7 operations
(p=0.0809). Non-infected patients with ADI>50 required
an average of 1.6 operations compared to 1.5 for those
with ADI <50 (p= 0.4168).
Nonunion rate was higher ADI >50 ADI both in infected
and non-infected patients while recurrence of infection
was seen only in infected patients without a statistically
significant difference between ADI > 50 and ADI>50
(p=0.7672). In infected patients, those who had ADI > 50
had a bigger difference between the admission and follow
up dysfunctional index, with more improvement in
function than those with ADI < 50 (the mean difference
was 22.1 and 6.4 respectively) but without statistical
significance (p=0.1162).
In non-infected patients, the findings were similar, with
the patients who had an ADI > 50 ADI showing a bigger
difference between the admission and follow up
dysfunctional index, compared with those with ADI<50
(the mean difference was 33.0 and 0.2 respectively),
demonstrating statistical significance (p=0.004). The
bothersome index showed the same pattern, with a
statistically significant improvement for those who were
admitted with a ADI>50 (p=0.006).
Conclusions
The ADI score in our sample appeared to be predictive in
two areas: 1) hospital course in patients with infection,
where a high ADI score correlated with longer hospital
stays and more surgeries, and 2) prognosis
(improvement in functional and bothersome indices)
which was better for non-infected patients who had high
ADI scores. A scoring system that predicts functional
outcome following surgical reconstruction of lower limb
injuries would be enormously useful. This study could
provide the basis for a new strategy regarding counseling
of patients. The combination of infection and a high ADI
may lead to more surgeries, more complications and
longer hospital stays that potentially would not result in
improved physical or social function.
.
Table 1: Comparison at admission
Infection Infected patients (n=47) Non-infected patients (n=37)
ADI Group < 50
(n=32)
≥ 50
(n=15) Test p-value
< 50
(n=26)
≥ 50
(n=11) Test p-value
Age (in years,
mean) 32.4 35.6 Two sample t-test 0.3893 28.4 35.6 Two sample t-test 0.1233
Duration of stay
(in days, mean) 106.4 162.8
Wilcoxon rank-
sum test 0.0645 113.4 139.4
Wilcoxon rank-sum
test 0.2875
Number of
surgeries
(mean)
1.7 2.7 Wilcoxon rank-
sum test 0.0809 1.5 1.6
Wilcoxon rank-sum
test 0.4168
Early surgical
complications*
12
(37.5%)
8
(53.3%)
Chi-Square test 0.355
4 (16.0%) 4(36.4%)
Chi-Square test 0.214
Two sample
binominal
proportion test
0.3061
Two sample
binominal proportion
test
0.1758
Admission
bothersome
index (mean)
39.9 61.9 Two sample t test 0.0015 22.8 57.8 Two sample t test <0.0001
Table 2: Improvement in Dysfunctional Index (by Infection Status and
ADI)
Infection ADI Group Number of
Patients
Admission
dysfunctional index
(mean, only for
patients with follow-up
information)
Follow-up
dysfunction
al index
(mean)
Mean
Difference
Mean Difference (95%
Confidence Interval)
p-
value
Infected
patients
(n=19)
ADI<50 13 31.2 24.8 6.4 -5.0 17.8
0.116
2
ADI≥50 6 56.6 34.6 22.1 1.0 43.1
Both 19 39.2 27.9 11.3 1.6 21.0
Non-
infected
patients
(n=15)
ADI<50 9 31.2 31.1 0.2 -14.1 14.4
0.00
43
ADI≥50 6 59.3 26.3 33.0 14.9 51.2
Both 15 42.5 29.2 13.3 0.0 26.7
Table 3: Improvement in Bothersome Index (by Infection Status and ADI)
Infection ADI Group Number of
Patients
Admission
bothersome index
(mean, only for
patients with follow-
up information)
Follow-up
bothersome
index
(mean)
Mean
Differe
nce
Mean Difference (95%
Confidence Interval) p-value
Infected patients
(n=16)
ADI<50 10 43.8 15.8 28.0 5.5 50.4
0.7646 ADI≥50 6 59.4 36.6 22.7 -15.2 60.7
Both 16 49.6 23.6 26.0 8.8 43.1
Non-infected
patients (n=15)
ADI<50 9 26.2 34.6 -8.4 -27.5 10.7
0.0046 ADI≥50 6 61.8 28.3 33.5 11.8 55.2
Both 15 40.4 32.0 8.4 -8.8 25.5
* negative number indicates worse result at final
Table 4: Improvement in Dysfunctional Index
(by ADI)
ADI
Group
Number of
Patients
Admission dysfunctional
index (mean, only for
patients with follow-up
information)
Follow-up
dysfunctional
index (mean)
Mean
Difference
Mean
Difference
(95%
Confidence
Interval)
p-value
ADI<5
0 22 31.2 27.4 3.8 12.1
0.0012 ADI≥5
0 12 58.0 30.4 27.5 39.4
Both 34 40.6 28.4 12.2 19.8