President's Perspective Late December 2014
Adapt or Die
Thomas S. Roukis, DPM, PhD, FACFAS
Scoring scales are important because they facilitate
determination of efficacy; allow for comparison of results of different
treatment methods in patients with the same disorder; and enable the
progress of patients before and at various intervals after treatment to
be compared in a meaningful manner.
An Internet search
uncovers at least 145 different anatomic/disease-specific foot and/or
ankle scoring scales from 1952 to 2013. Some of these systems
incorporate subjective and objective variables into a numerical scale,
such as a 0–100 point distribution. Others lump the subjective variables
into a non-numerical scale, such as “excellent,” “good,” “fair” and
“poor.” Objective parameters are usually limited to radiographic
parameters and clinical factors. These make sense to the everyday
clinician and surgeon because this is how we usually judge our
interpretation of success. But while this may be helpful to us
individually as foot and ankle surgeons, it does not allow comparison
with other providers, patients or surgical techniques.
becoming more important to understand as we become increasingly judged
in “pay for performance” by insurance and government agencies. Taking
these factors into consideration, an ideal scoring scale would:
- be suitable for both pre-operative and post-operative assessments;
- not require sophisticated equipment for data collection;
- not be complicated by too many parameters;
- use parameters that represent the overall outcome;
- have results expressed as a numerical value for ease of comparison.
ACFAS had the vision in 1999 to begin the lengthy process of developing
and validating anatomic/disease-specific scoring scales for foot and
ankle surgery. However, some confusion occurred about the validation
process employed, and the benefit for using these new scales was lost.
In response, in 2008, the ACFAS Board of Directors named a task force to
specifically reevaluate the scoring scales to determine if they met the
criteria for validity. This process continued in 2009–2010 when the
task force was charged with evaluating all previous information
regarding the ACFAS Scoring Scales to reevaluate its validity. I was
fortunate enough to chair this task force with truly outstanding ACFAS
members who collectively spent more than 150 hours gathering, reviewing,
discussing, analyzing and ultimately publishing the data (1). Those
efforts resulted in a full validation of the original ACFAS Scoring
It is clear that the scales were developed with a
systematic and comprehensive approach, and both the statistical methods
and instrument development process were appropriately conducted.
Furthermore, modules 1 and 2 were rigorously assessed and met the
standards for validity, reliability and sensitivity to change. These are
the necessary elements to determine if a scoring scale is valid for
The next step is for all foot and ankle surgeons to use
these ACFAS Scoring Scales. Further, I believe that all ACFAS research
grant proposals and manuscripts/posters presented at the Annual
Scientific Conference should be given preferential treatment if they
incorporate the ACFAS Scoring Scales into their research design. In
doing so, we will be able to continually refine the scales and improve
the ease and efficacy of data collection using these instruments. This
will also lead to firmly established quality surgical outcomes in the
medical community for all professions, insurance companies and
government agencies to see. If we fail to see the ACFAS Scoring Scales,
they will be replaced by other instruments or metrics developed by
outside medical societies, insurance carriers or governmental agencies.
This is dangerous and simply cannot happen. Will you adapt and use the ACFAS Scoring Scales or let them die?
Cook JJ, Cook EA, Rosenblum BI, Landsman AS, Roukis TS. Validation of
the American College of Foot and Ankle Surgeons Scoring Scales. J. Foot Ankle Surg. 50(4):420-429, 2011.