G Model

FAS 1010 No. of Pages 5

Foot and Ankle Surgery xxx (2016) xxxxxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

American Orthopaedic Foot and Ankle Society anklehindfoot scale: A

cross-cultural adaptation and validation study from Iran
Amir Reza Vosoughi, MDa , Narges Roustaei, PhDb,c, Hamideh Mahdaviazad, MDd,*
a
Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
b
Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
c
Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
d
Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

A R T I C L E I N F O A B S T R A C T

Article history: Background: The use of valid and reliable outcome rating scales is essential for evaluating the result of
Received 10 December 2016 different treatments and interventions. The purposes of this study were to translate and culturally adapt
Received in revised form 11 January 2017 the American Orthopaedic Foot and Ankle Society anklehindfoot scale (AOFAS-AHFS) into Persian
Accepted 3 February 2017
languages and evaluate its psychometric properties.
Available online xxx
Methods: Forwardbackward translation and cultural adaptation method were used to develop Persian
version of AOFAS-AHFS. From March to July 2016, one hundred consecutive patients with ankle and
Keywords:
hindfoot injuries were included. Internal consistency and reproducibility were evaluated using
Translation
Validation study
Cronbachs alpha, Spearmans rank correlation coefcient and Intraclass correlation coefcient (ICC)
Reliability respectively. Construct validity reported which compare the outcome rating scale measurements with
AOFAS Short Form-36 (SF-36), also convergent and discriminant validity evaluated using Spearmans rank
Foot and ankle correlation coefcient.
Results: Mean age (SD) of the patients was 41.95  13.45 years. Cronbachs a coefcient, Spearmans rho
and ICC values were 0.71, 0.89 and 0.90 respectively. Total score of AOFAS-AHFS and SF-36 domains has a
correlation ranged between 0.170.55. Spearmans rank correlation coefcient of 0.4 was exceeded by all
items with the exception of stability. The Spearmans rank correlation between each item in functional
subscales with its own subscales was higher than the correlation between these items and other
subscales.
Conclusions: Persian version of AOFAS-AHFS provides additional reliable and valid instrument which can
be used to assess broad range of patients with foot and ankle disorders that speaking in Persian. However,
it seems that the original version of AOFAS-AHFS needs some revisions.
2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction
The ankle injuries are among the most common injuries
sustained during sporting activities. These injuries may result in
functional disability, chronic pain, and deprivation from daily
activities [1,2]. Evaluating the outcomes of various medical and
surgical treatment modalities for foot and ankle injuries should be
done by standard scores [3]. Over the recent years, different
outcome rating scales have been used as subjective measures in
the eld of foot and ankle surgery [415]. Some outcome rating
scales such as Medical Outcomes Study Short Form-36 (SF-36)
* Corresponding author. Fax: +98 713 6234504.
E-mail addresses: mahdavih@sums.ac.ir, drmahdavih@gmail.com
(H. Mahdaviazad).
assess overall health status [16], whereas others evaluate a specic
anatomic region or isolated disease [7,10,13,17,18].
In 1994, American Orthopaedic Foot and Ankle Society (AOFAS)
has provided specic scales to measure the foot and ankle injuries,
quantitatively. The AOFAS scales evaluate four different anatomic
regions of the foot and ankle: anklehindfoot scale, midfoot scale,
hallux metatarsophalangealinterphalangeal (MTPIP) scale, and
lesser metatarsophalangealinterphalangeal scale [11]. AOFAS
anklehindfoot scale, as one of the most popular rating scales in
foot and ankle surgery, has been developed with the best of notice
as well as easy to use and understand. Original version of AOFAS
anklehindfoot scale is in English language and according to the
best of our research and knowledge; only three published studies
approved its validation in Portuguese, German, and Turkish
cultures [8,19,20]. So the purposes of this study were to translate
and culturally adapt AOFAS anklehindfoot scale into Persian

http://dx.doi.org/10.1016/j.fas.2017.02.007
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: A.R. Vosoughi, et al., American Orthopaedic Foot and Ankle Society anklehindfoot scale: A cross-cultural
adaptation and validation study from Iran, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.007
G Model
FAS 1010 No. of Pages 5
2 A.R. Vosoughi et al. / Foot and Ankle Surgery xxx (2016) xxxxxx
language and then evaluate its psychometric properties consisting
of reliability and validity in comparison to SF-36 in patients with
ankle and/or hindfoot pathologies.
2. Methods
2.1. Setting and patients
After approval of the study by the medical ethic committee of
our university, consecutive patients with ankle and/or hindfoot
pathologies were enrolled at the main referral outpatient clinic of
foot and ankle surgery in south of Iran from March 2016 to July
2016, prospectively. We selected patients more than 20 years of age
with unilateral ankle and/or hindfoot pathology besides ability to
read and write in Persian language. Exclusion criteria were using
leg cast, acute trauma, concomitant injuries to other parts of the
injured limb, and cognitive changes. Also patients who did not sign
the written informed consent form to participate in the survey
were excluded. In order to test rating scale reproducibility,
participants were not permitted to switch to a new medication
or any other procedures for a period of 14 days after rst visit.
Socio-demographic data of the patients including age, gender,
educational level, occupation, duration of injuries, and diagnosis
were recorded on arrival. Then prepared AOFAS anklehindfoot
scale in Persian language as described below was lled for each
patient. Objective parts of the nal version of AOFAS ankle
hindfoot scale in Persian language were completed by the
orthopaedic foot surgeon and his experienced assistant. Validated
SF-36 inquiry form in Persian language [16] was lled by the
patients.
2.2. Validation and translation of AOFAS anklehindfoot scale
The AOFAS anklehindfoot scale is a 9-item questionnaire divided
into three subscales: pain (40 points), functional aspects (50 points)
and alignment (10 points). Scores ranged between 0 to 100 points;
0 point indicates the worst and 100 points show the best.
The translation and cultural adaptation method were con-
ducted in three stages, according to the standard rules in the
literature [21]. In the rst stage, primary translation from English
to Persian language was done by two independent Persian
translators who were aware of the purpose of the study. Both
translations were compared and necessary changes were made in
order to achieve an integrated primary version of AOFAS ankle
hindfoot scale in Persian language. In the second stage, backward
translation of integrated primary version into English language
was done by a PersianAmerican person blinded to the purpose of
the study. After comparing primary version with backward
translation by a committee of translators and authors, the nal
version of AOFAS anklehindfoot scale in Persian language was
prepared. In the third stage, cultural adaptation was performed by
randomly selecting 10 patients with ankle and hindfoot patholo-
gies. Then they were asked to reply to the subjective questions of
the nal version of AOFAS anklehindfoot scale in Persian language
questionnaire. To assess the understanding level of each question,
the alternative choice of difcult to understand was added. Each
question should be revised if over 10% of the population chosen
difcult to understand choice as the response.
2.3. Assessment of psychometric properties
2.3.1. Reliability
Reliability is the ability of an outcome rating scale to achieve
same results after being applied in the same situation for the same
person [3]. In this study, both intra-rater and inter-rater
reliabilities were assessed. Inter-rater reliability was calculated
Please cite this article in press as: A.R. Vosoughi, et al., American Orthopaedic Foot and Ankle Society anklehindfoot scale: A cross-cultural
adaptation and validation study from Iran, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.007
using achieved data after exam of the cases by the orthopaedic foot
surgeon and his assistance on arrival with interval period between
two exams of at least one hour. After 2 weeks, thirty patients were
examined again by the assistant in order to get the intra-rater
reliability.
2.3.2. Validity
Validity shows how well a test measures what it is purported to
measure actually [3]. Due to the lack of a gold standard, reported
validity in the present study was calculated from comparing AOFAS
anklehindfoot scale with SF-36. Convergent validity, the correla-
tion between each item and its own subscale, and discriminate
validity, the correlation between each item with other subscales,
were measured. In addition, the content validity was evaluated on
arrival by calculating the proportion of the patients with the
maximum (ceiling) and minimum (oor) values in relative to the
total number of patients.
2.3.3. Data analysis
Statistical analysis was carried out using the SPSS software
version 16 (SPSS Inc., Chicago, IL, USA). The differences were
considered statistically signicant at a P value of less than 0.05.
Frequency, percentage, mean, and standard deviation of different
variables were calculated. Further analyses were conducted as
below:
The reliability of the questionnaire regarding internal consis-
tency (IC) was evaluated. The Cronbachs a coefcient 0.7 was
considered acceptable for internal consistency. Intraclass correla-
tion coefcient (ICC) was used to assess inter-rater reliability. ICC
(3,1) was calculated using a 2-way, mixed-model of variance under
consistency. Values of 0.4 were considered satisfactory
(r  0.81 shown excellent; 0.61  r  0.80, very good; 0.41  r
 0.60, good; 021  r  0.40, fair; r  0.2, poor) [22]. For evaluating
intra-rater reliability, Spearmans rank correlation coefcient was
used. Correlation coefcients more than 0.6, between 0.30.6, and
lower than 0.3 were indicated high, moderate, and low correlation,
respectively [23].
To evaluate the construct validity of AOFAS anklehindfoot
scale, we used Spearmans rank correlation coefcient in order to
calculate relationship between total score of AOFAS anklehind-
foot scale on arrival and eight domains of SF-36 quality of life scale
as a gold standard. Convergent validity was considered to be
acceptable when the correlation between one item and its original
subscale was 0.4 or higher [24]. Discriminate validity was
considered to be acceptable when the correlation between one
item and its own subscale was higher than the correlation between
that item and other subscales [24]. Floor and ceiling effect was
considered as a more than 15% of the patients achieved lowest and
highest scores [25].
3. Result
During the study period, one hundred patients accepted to
participate in the survey. Demographic and clinical diagnoses of
the subjects are summarized in Table 1.
In cultural adaptation process, one item was modied. Second
item of the functional subscale regarding maximum walking
distance, blocks was changed to maximum walking distance,
100 m, because blocks are not used for estimation of distance in
Iran. Other items were easy to understand for the majority of
participants in the pilot study.
3.1. Reliability
Cronbachs a coefcient was 0.71 for functional subscale at the
rst administration of AOFAS anklehindfoot scale. The minimum
G Model
FAS 1010 No. of Pages 5

A.R. Vosoughi et al. / Foot and Ankle Surgery xxx (2016) xxxxxx 3

Table 1 Table 3
Demographic characteristics of participants in the survey (n = 100) Construct validity by means of the Spearmans rank correlation coefcients
between the total score of the Persian version of the AOFAS and different domains of
Variables Number (%) or mean  SD the SF36 questionnaire.
Age (y) 41.95  13.45
SF-36 domainsa Validated AOFAS anklehindfoot scale in Persian
Gender
languageb
Male 51 (51%)
Female 49 (49%) Physical functioning (PF) 0.55
Education level Role-physical (RP) 0.42
Illiterate 5 (5%) Bodily pain (BP) 0.37
Under diploma 30 (30%) General health (GH) 0.23
Diploma and similar degree 34 (34%) Vitality (VT) 0.17
Bachelor and higher 31 (31%) Social functioning (SF) 0.27
Occupation Role-emotion (RE) 0.37
Employee 37 (37%) Mental health (MH) 0.34
Labor 14 (14%) Physical Component 0.55
Self-employee 18 (18%) Summary Scale
Housewife 31 (31%) Mental Component 0.39
Duration of injury(m) 40.28  72.49 Summary Scale
Diagnosis
Spearmans rank correlation coefcients equal or greater than 0.30 are in bold.
Cartilage injuries 31 (31% a
SF-36 Short Form-36 health survey.
Tendon injuries 21 (21%) b
AOFAS American Orthopaedic Foot and Ankle Society.
Ligament injuries 17 (17%)
Old trauma 9 (9%)
Deformities 10 (10%)
Plantar fasciitis 12 (12%)
Table 4
Convergent and discriminate validity of Persian version of AOFAS anklehindfoot
scale.
acceptable level of Spearmans rank correlation coefcient was
Item in subscales Persian version of AOFAS anklehindfoot scale
seen for all subscales. The analysis of inter-rater and intra-rater
reliability presented ICC of greater than 0.8 for all items (Table 2). Pain Function Alignment
Pain 1.00 0.32 0.03
3.2. Validity Function
Restraints in activities 0.04 0.52 0.25
Maximum walking distance 0.45 0.63 0.10
As shown in Table 3, correlation between the total score of Walking surface 0.44 0.64 0.14
AOFAS anklehindfoot scale and SF-36 PF domain was 0.55. Total Gait abnormality 0.40 0.72 0.40
score of AOFAS-AHFS and other seven domains of SF-36 have a Sagittal mobility 0.02 0.65 0.63
correlation ranged between 0.170.423. Hindfoot mobility 0.01 0.61 0.57
Stability 0.00 0.21 0.17
In addition, correlation between total score of AOFAS-AHFS and Alignment 0.03 0.59 1.00
SF-36 PCS was 0.55 that this value was higher than correlation
Correlation coefcient between each item and own subscale is in bold.
between total score of AOFAS-AHFS and SF-36 MCS (r = 0.3).

3.3. Convergent and discriminate validity

As demonstrated in Table 4, convergent validity was approved

3.4. Floor and ceiling effect
for all items of functional subscale of Persian version of AOFAS
anklehindfoot scale except stability using Spearmans rank
Mean (SD) of total score of Persian version of AOFAS ankle
correlation coefcient. Spearmans rank correlation coefcient
hindfoot scale and SF- 36 items in addition to oor and ceiling
between all items of functional subscale of Persian version of
scores is shown in Table 5. Floor and ceiling effects were calculated
AOFAS anklehindfoot scale with its own subscales was higher
3% and 0% in the rst administration of Persian version of AOFAS
than the coefcient between these items and other subscales
anklehindfoot scale. In SF- 36, oor and ceiling effect occurred in
including pain and alignment (discriminate validity).
two and three items respectively.

Table 2
Intra and inter-reliability of the Persian version of AOFAS subscales using Spearmans rank correlation coefcient.

Questions Foot surgeon Assistant Re-test Intra-rater reliability Inter-rater reliability

(mean  SD) (mean  SD) (mean  SD) (Spearmans rho) ICC (95%CI)
Pain (040) 19.41  12.5 19.18  12.15 21.18  10.66 0.84 0.99 (0.990.99)
Function (050) 36.95  9.01 36.59  9.42 35.71  9.61 0.88 0.94 (0.910.95)
Activity limitation 7.24  2.05 7.11  1.59 6.79  2.07 0.87 1.00 (1.001.00)
Maximum walking distance 3.26  2.08 3.19  2.05 3.12  1.98 0.90 1.00 (1.001.00)
Walking surface 2.15  1.86 2.22  1.88 1.87  2.02 1.00 0.98 (0.980.99)
Gait abnormality 5.86  2.63 5.95  2.58 5.76  2.24 0.85 0.99 (0.990.99)
Sagittal motion 6.74  2.33 6.62  2.45 6.71  2.14 0.92 0.92 (0.890.95)
Hind-foot motion 4.38  2.38 4.41  2.36 4.32  2.11 0.92 0.93 (0.900.95)
Stability 7.41  2.06 7.39  209 7.53  1.91 0.69 0.98 (0.980.99)
Alignment (010) 9.17  2.11 9.22  2.08 9.11  1.93 0.82 1.00 (1.001.00)
Total score 65.33  18.56 64.25  19.21 66  16.97 0.89 0.90 (0.860.93)

SD: Standard deviation.

Spearmans rho: Spearmans rank correlation coefcient.
ICC: Intraclass Correlation Coefcient.

Please cite this article in press as: A.R. Vosoughi, et al., American Orthopaedic Foot and Ankle Society anklehindfoot scale: A cross-cultural
adaptation and validation study from Iran, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.007
G Model
FAS 1010 No. of Pages 5
4 A.R. Vosoughi et al. / Foot and Ankle Surgery xxx (2016) xxxxxx
Table 5
Ceiling and oor scores of Persian version of AOFAS anklehindfoot scale and SF-36 domains.
Questionnaire Mean  SD
Persian version of AOFAS anklehindfoot scale 65.33  18.57
SF-36 domains
Physical functioning (PF) 54.36  27.39
Role-physical (RP) 29.75  38.71
Bodily pain (BP) 41.16  41.40
General health (GH) 57.43  24.66
Vitality (VT) 61.56  21.67
Social functioning (SF 67.00  34.47
Role-emotion (RE) 53.00  30.16
Mental health (MH) 58.71  23.0
4. Discussion
Recently, there is an increased concern in using objective
indices and scores to evaluate care of the patients and outcome of
treatments. Using original version in English language of outcome
rating scales is not possible in other cultures. So translation and
psychometric evaluation in a specic cultural context are a
necessity [26,27]. The present study was conducted to translate,
cross-culturally adapt, and verify the psychometric properties of
the original AOFAS anklehindfoot scale into a Persian version.
During translation and cultural adaptation process, our
subjects had no any problem regarding concept of questions
except one in functional subscale described distance as block.
Also it should be mentioned that 4 out of 9 questions in AOFAS
anklehindfoot scale are subjective items fullled by the patients
and others were answered by the examiner. In addition,
approximately two-third of the patients had a diploma or a
higher educational certicate.
Persian version of AOFAS anklehindfoot scale had high internal
consistency (a coefcient of 0.71), intra-reliability (ICC: 0.89), and
inter-reliability (ICC: 0.90). Our results were the same as
Portuguese and Turkish versions of AOFAS anklehindfoot scale.
Intra-reliability and inter-reliability of Portuguese version of
AOFAS anklehindfoot scale were 0.89 and 0.93, and in Turkish
version were 0.932 and 0.959, respectively [8,20]. Average intervals
between rst and repeated measurements to calculate reliability in
Portuguese and Turkish versions were 9 and 7 days, respectively. It
was shorter than 14 days in the present study.
In comparison with SF-36 questionnaire as the gold standard,
we found good to fair correlation between total score of AOFAS
anklehindfoot scale and all domains of SF-36. The highest
correlation was related to total score of AOFAS anklehindfoot
scale and SF-36 PF, RP, and PCS domains, respectively (r: 0.56, 0.42,
and 0.55). The weakest correlation was related to total score of
AOFAS anklehindfoot scale and SF-36 VT (r: 0.17). Portuguese
study demonstrated good correlation between total score of AOFAS
anklehindfoot scale and seven items of SF-36 (values ranged
between 0.460.83) [8]. Whereas Turkish study reported fair
correlation between AOFAS anklehindfoot scale and SF-12 PCS (r:
0.27) and poor correlation between AOFAS anklehindfoot scale
and SF-12 MCS (r: 0.03) [20]. The study by SooHoo et al. [17]
reported low correlations between AOFAS anklehindfoot scale
and all domains of SF-36 (0.020.36). The construct validity of
AOFAS anklehindfoot scale was tested with all 8 domains of SF-
36 and two summary scales in this survey, as the same as ours.
Calculating of the convergent and discriminate validities was
disclosed acceptable validity except stability subscale in AOFAS
anklehindfoot scale. However, this result would be interpreted
with caution for two reasons. First, two subscales of questionnaire
including pain and alignment have been evaluated with a single
question. Second, there were no similar results regarding
Please cite this article in press as: A.R. Vosoughi, et al., American Orthopaedic Foot and Ankle Society anklehindfoot scale: A cross-cultural
adaptation and validation study from Iran, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.007
Celling scores N (%) Floor scores N (%)
3.0 (3%) 0.0 (0%)
4.0 (4%) 0.0 (0%)
18 (18%) 53 (53%)
27 (27%) 39 (39%)
2.0 (2%) 0.0 (0%)
1.0 (1%) 1.0 (1%)
38 (38%) 6.0 (6%)
12 (12%) 1.0 (1%)
1.0 (1%) 0.0 (0%)
convergent and discriminate validities of AOFAS anklehindfoot
scale for comparison.
The present study had several potential limitations. Limited
number of studies evaluated psychometric properties of AOFAS
anklehindfoot scale made desirable comparison difcult. For
example, the German version of its scale was published in German
language and we could not use it. Furthermore, we did not
compare the results between patients and healthy persons.
In conclusion, Persian version of AOFAS anklehindfoot scale
provides a reliable and valid instrument for comparing the
outcomes of different ankle and hindfoot interventions in Persian
language population. However, it seems that the original version of
AOFAS anklehindfoot scale needs revisions in some areas like
denition of block in maximum walking distance question. Our
results should be approved by the other studies with more cases.
Conict of interest
The authors declare that they have no conict of interest.
Funding
This study was funded by Vice Chancellor for Research of Shiraz
University of Medical Science. (Grant number 56-11570).
Acknowledgements
The authors would like to thank the Vice Chancellor for
Research of Shiraz University of Medical Science for nancial
support (grant No. 56-11570), and appreciate Mr. A. Tarang for
interviewing and examination of the patients.
References
[1] Walls RJ, Ross KA, Fraser EJ, Hodgkins CW, Smyth NA, Egan CJ, et al. Football
injuries of the ankle: a review of injury mechanisms, diagnosis and
management. World J Orthop 2016;7(January (1)):819, doi:http://dx.doi.
org/10.5312/wjo.v7. i1.8.
[2] Kusnezov NA, Yazdanshenas H, Garcia E, Shamie AN. Epidemiology of
musculoskeletal injury in the California lm and motion picture industry.
Rev Environ Health 2016;31(June (2)):2517, doi:http://dx.doi.org/10.1515/
reveh-2015-0023.
[3] Button G, Pinney S. A meta-analysis of outcome rating scales in foot and ankle
surgery: is there a valid, reliable, and responsive system? Foot Ankle Int
2004;25(8):5215.
[4] Huh JW, Eun IS, Ko YC, Park MJ, Hwang KM, Park SH, et al. Reliability and
validity of the Korean version of the foot function index. J Foot Ankle Surg
2016;55(4):75961.
[5] Garcs JBG, Winson I, Goldhahn S, Castro MD, Swords MP, Grujic L, et al.
Reliability, validity and responsiveness of the Spanish Manchester-Oxford Foot
Questionnaire (MOXFQ) in patients with foot or ankle surgery. Foot Ankle Surg
2015;22(1):5970.
[6] Negahban H, Mazaheri M, Salavati M, Sohani SM, Askari M, Fanian H, et al.
Reliability and validity of the foot and ankle outcome score: a validation study
from Iran. Clin Rheumatol 2010;29(5):47986.
G Model
FAS 1010 No. of Pages 5
A.R. Vosoughi et al. / Foot and Ankle Surgery xxx (2016) xxxxxx
[7] Nilsson GM, Eneroth M, Ekdahl CS. The Swedish version of OMAS is a reliable
and valid outcome measure for patients with ankle fractures. BMC
Musculoskelet Disord 2013;14(1):14712474.
[8] Rodrigues RC, Masiero D, Mizusaki JM, Imoto AM, Peccin MS, Cohen M, et al.
Translation, cultural adaptation and validity of the American Orthopaedic
Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Acta Ortop Bras
2008;16(2):10711.
[9] Kim JB, Kim JK, Seo SG, Lee DY. Validity, reliability, and responsiveness of the
Korean version of American Academy of Orthopedic Surgeons Foot and Ankle
questionnaire. J Foot Ankle Surg 2015;54(1):4650.
[10] Domsic RT, Saltzman CL. Ankle osteoarthritis scale. Foot Ankle Int
1998;19:46671.
[11] Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M.
Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes.
Foot Ankle Int 1994;15(7):34953.
[12] Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of
foot pain and disability. J Clin Epidemiol 1991;44:56170.
[13] Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome
score for ankle ligament reconstruction. Foot Ankle Int 2001;22(10):
78894.
[14] Martinelli N, Romeo G, Bonifacini C, Vigano M, Bianchi A, Malerba F. Validation
of the Italian version of the Oxford Ankle Foot questionnaire for children. Qual
Life Res 2016;25(1):11723.
[15] Cster MC, Bremander A, Rosengren BE, Magnusson H, Carlsson , Karlsson
MK. Validity, reliability, and responsiveness of the Self-reported Foot and
Ankle Score (SEFAS) in forefoot, hindfoot, and ankle disorders. Acta Orthop
2014;85(2):18794.
[16] Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health
Survey (SF-36): translation and validation study of the Iranian version. Qual
Life Res 2005;14(3):87582.
Please cite this article in press as: A.R. Vosoughi, et al., American Orthopaedic Foot and Ankle Society anklehindfoot scale: A cross-cultural
adaptation and validation study from Iran, Foot Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.02.007
5
[17] SooHoo NF, Shuler M, Fleming LL. Evaluation of the validity of the AOFAS
clinical rating systems by correlation to the SF-36. Foot Ankle Int 2003;24
(1):505.
[18] Mutlu EK, Celik D, Kilioglu , Ozdincler AR, Nilsson-Helander K. The Turkish
version of the Achilles tendon Total Rupture Score: cross-cultural adaptation,
reliability and validity. Knee Surg Sports Traumatol Arthrosc 2015;23
(8):242732.
[19] Kostuj T, Schaper K, Baums MH, Lieske S. Eine Validierung des AOFAS-Ankle-
Hindfoot-Scale fsur den deutschen Sprachraum. Fu Sprunggelenk
2014;12:1006.
[20] Akbaba YA, Celik D, Ogut RT. Cross-cultural adaptation, reliability, and validity
of Turkish version of the American Orthopaedic Foot and Ankle Society Ankle-
hindfoot Scale. J Foot Ankle Surg 2016;55(6):113944.
[21] Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of
cross-cultural adaptation of self-report measures. Spine 2000;25:318691.
[22] Shrout PE, Fleiss JL. Intraclass correlation: uses in assessing rater reliability.
Psychol Bull 1979;86:4208.
[23] Marx RG, Menezes A, Horovitz L, Jones EC, Warren RF. A comparison of two
time intervals for test-retest reliability of health status instruments. J Clin
Epidemiol 2003;56:7305.
[24] Campbell DT, Fiske DW. Convergent and discriminant validation by the
multitrait-multimethod matrix. Psychol Bull 1959;56(2):81105.
[25] Goksel Karatepe A, Gunaydin R, Kaya T, Karlibas U, Ozbek G. Validation of the
Turkish-version of the foot and ankle outcome score. Rheumatol Int
2009;30:16973.
[26] Laine C, Davidoff F. Patient centered medicine: a professional evolution. JAMA
1996;275:1526.
[27] Clancy CM, Eisenberg JM. Outcomes research: measuring the end results of
care. Science 1998;282:2456.