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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)

Methodology

Introduction Surgical reconstruction of lower limb injuries in warwounded 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 selfreported 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.

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).

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.

Infected patients (n=47)

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.

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).

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.

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).

Table 1: Comparison at admission Infection

Conclusions

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

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.

Table 2: Improvement in Dysfunctional Index (by Infection Status and ADI) Duration of stay (in days, mean) Number of surgeries (mean)

106.4

1.7

162.8

2.7

Wilcoxon ranksum test Wilcoxon ranksum test

Chi-Square test Early surgical complications*

Admission bothersome index (mean)

12 (37.5%)

39.9

8 (53.3%)

61.9

Two sample binominal proportion test

Two sample t test

0.0645

0.0809

113.4

1.5

139.4

1.6

0.355

Wilcoxon rank-sum test

Chi-Square test 4 (16.0%)

4(36.4%)

0.3061

0.0015

Wilcoxon rank-sum test

22.8

57.8

Two sample binominal proportion test

Two sample t test

0.2875

0.4168

Infection

ADI Group

Number of Patients

Admission Follow-up dysfunctional index dysfunction Mean (mean, only for al index Difference patients with follow-up (mean) information)

Table 3: Improvement in Bothersome Index (by Infection Status and ADI) Mean Difference (95% Confidence Interval)

pvalue

0.214

0.1758

<0.0001

Infection

Infected patients (n=19)

Noninfected patients (n=15)

ADI<50 ADI≥50 Both ADI<50 ADI≥50 Both

13 6 19 9 6 15

31.2 56.6 39.2 31.2 59.3 42.5

24.8 34.6 27.9 31.1 26.3 29.2

6.4 22.1 11.3 0.2 33.0 13.3

-5.0 1.0 1.6 -14.1 14.9 0.0

17.8 43.1

0.116 2

21.0 14.4 51.2 26.7

ADI Group

Admission Follow-up bothersome index Mean Number of bothersome Mean Difference (95% (mean, only for Differe p-value Patients index Confidence Interval) patients with follownce (mean) up information)

ADI Group

Infected patients (n=16)

.

0.00 43

Table 4: Improvement in Dysfunctional Index (by ADI)

Non-infected patients (n=15)

ADI<50

10

43.8

15.8

28.0

5.5

ADI≥50

6

59.4

36.6

22.7

-15.2

Both

16

49.6

23.6

26.0

8.8

43.1

ADI<50

9

26.2

34.6

-8.4

-27.5

10.7

ADI≥50

6

61.8

28.3

33.5

11.8

55.2 0.0046

Both

15

40.4

32.0

8.4

-8.8

25.5

* negative number indicates worse result at final

Mean Difference (95% Confidence Interval)

Number of Patients

Admission dysfunctional index (mean, only for patients with follow-up information)

22

31.2

27.4

3.8

12.1

12

58.0

30.4

27.5

39.4

34

40.6

28.4

12.2

19.8

50.4

Follow-up Mean dysfunctional Difference index (mean)

p-value

60.7 0.7646 ADI<5 0 ADI≥5 0 Both

0.0012

The Short Musculoskeletal Functional Assessment (SMFA) score and surgical outcomes in Amman, Jordan  

Rasheed M. Fakhri, Nancy Foote and Carrie Teicher

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