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