Validity And Reliability of the Indonesian Version of the American Orthopaedic Foot And Ankle Society Ankle-Hindfoot Score as an Instrument for Assessing Ankle and Hindfoot Function
Abstract
Background: Standardized outcome instruments are essential for evaluating pain, function, and clinical status in patients with ankle and hindfoot disorders. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score is widely used internationally, but a formally validated Indonesian-language version is needed for use in Indonesian clinical practice and research. Objective: This study evaluated the validity and reliability of the Indonesian version of the AOFAS Ankle-Hindfoot Score in adults with ankle and hindfoot disorders. Methods: A methodological validation study was conducted in a multicenter clinical setting. Adults with traumatic, postoperative, or degenerative ankle and hindfoot disorders who could understand Indonesian and provide informed consent were included. The AOFAS score was assessed together with the Foot and Ankle Outcome Score (FAOS) and Short Form-36 (SF-36). Internal item validity was examined using Pearson correlation, internal consistency using Cronbach’s alpha, and inter-rater reliability using Cohen’s kappa. Convergent validity was assessed by correlation with FAOS and SF-36. Floor and ceiling effects were also examined. Results: Eighty-seven participants were included in the descriptive analysis. The mean age was 40.0 ± 16.1 years, 58.6% were male, and 44.8% had a university education. The mean AOFAS Ankle-Hindfoot Score was 59.03 ± 19.72. In the 81 participants included in item-level validation and inter-rater analyses, all nine AOFAS items were valid, with item correlations ranging from 0.623 to 0.856 and p < 0.001. Internal consistency was high (Cronbach’s alpha = 0.851). Inter-rater reliability was excellent, with Cohen’s kappa values ranging from 0.911 to 1.000 and a mean kappa of 0.975. Convergent correlations were strong with FAOS (r = 0.850) and SF-36 (r = 0.911), both p < 0.001. No floor or ceiling effect was observed for the total AOFAS score. Conclusion: The Indonesian AOFAS Ankle-Hindfoot Score demonstrated good internal validity, high internal consistency, excellent inter-rater agreement, and strong convergent validity in the study population. It can therefore be considered a useful instrument for assessing ankle and hindfoot function in Indonesian adults, although further studies should evaluate responsiveness and performance in specific non-traumatic populations.
References
- Erard MUE, Sheean MAJ, Sangeorzan BJ. Triple arthrodesis for adult-acquired flatfoot deformity. Foot Ankle Orthop. 2019;4(3):2473011419849609.
- Dimmer A, Baird R, Puligandla P. Role of practice standardization in outcome optimization for CDH. World J Pediatr Surg. 2024;7(2):e000783.
- Hogan MV, Mani SB, Chan JY, Do H, Deland JT, Ellis SJ. Validation of the Foot and Ankle Outcome Score for Hallux Rigidus. HSS J. 2016;12(1):44–50.
- Sinsky CA, Bavafa H, Roberts RG, Beasley JW. Standardization vs customization: finding the right balance. Ann Fam Med. 2021;19(2):171–177.
- Paget LDA, Sierevelt IN, Tol JL, Kerkhoffs GMMJ, Reurink G. The completely patient-reported version of the American Orthopaedic Foot and Ankle Society (AOFAS) score: a valid and reliable measurement for ankle osteoarthritis. Journal of ISAKOS. 2023;8(5):345–351.
- Van Lieshout EMM, De Boer AS, Meuffels DE, Den Hoed PT, Van der Vlies CH, Tuinebreijer WE, et al. American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-hindfoot Score: a study protocol for the translation and validation of the Dutch language version. BMJ Open. 2017;7(2):e012884.
- De Boer AS, Tjioe RJC, Van Der Sijde F, Meuffels DE, Den Hoed PT, Van Der Vlies CH, et al. The American Orthopaedic Foot and Ankle Society Ankle-hindfoot Scale: translation and validation of the Dutch language version for ankle fractures. BMJ Open. 2017;7(8):e017040.
- Niki H, Aoki H, Inokuchi S, Ozeki S, Kinoshita M, Kura H, et al. Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders I: development of standard rating system. J Orthop Sci. 2005;10(5):457–465.
- Frank VJ, Lichte P, Gutteck N, Bouillon B, Arbab D. Comparison of the European Foot and Ankle Score (EFAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) in patients with foot and ankle surgery. Foot Ankle Surg. 2025;S1268773125001134.
- Vosoughi AR, Roustaei N, Mahdaviazad H. American Orthopaedic Foot and Ankle Society ankle–hindfoot scale: a cross-cultural adaptation and validation study from Iran. Foot Ankle Surg. 2018;24(3):219–223.
- Cruchinho P, López-Franco MD, Capelas ML, Almeida S, Bennett PM, Miranda da Silva M, et al. Translation, cross-cultural adaptation, and validation of measurement instruments: a practical guideline for novice researchers. J Multidiscip Healthc. 2024;17:2701–2728.
- Ficke J, Byerly DW. Anatomy, bony pelvis and lower limb: foot. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
- Blom A, Warwick D, Whitehouse M, Solomon L, editors. Apley & Solomon’s system of orthopaedics and trauma. 10th ed. Boca Raton (FL): CRC Press; 2018.
- Morton DA, Foreman KB, Albertine KH. Leg. In: The Big Picture: Gross Anatomy, Medical Course & Step 1 Review. 2nd ed. New York: McGraw-Hill Education; 2018.
- Miller MD, Thompson SR. DeLee, Drez, & Miller’s orthopaedic sports medicine: principles and practice. Philadelphia: Elsevier; 2020.
- Universitas Udayana. Buku Panduan Belajar Dokter Muda Orthopaedi dan Traumatologi. Denpasar: Universitas Udayana; [date not provided].
- Poolman RW, Swiontkowski MF, Fairbank JCT, Schemitsch EH, Sprague S, de Vet HCW. Outcome instruments: rationale for their use. J Bone Joint Surg Am. 2009;91(Suppl 3):41–49.
- Lafave MR, Katz L. Validity and reliability of the Standardized Orthopedic Assessment Tool (SOAT): a variation of the traditional objective structured clinical examination. J Athl Train. 2014;49(3):373–380.
- D’souza JJ. American Orthopedic Foot-and-Ankle Society Score, where are we now? A narrative review of quality of life measures in foot-and-ankle surgery. Open Access Maced J Med Sci. 2020;8(F):133–136.
- Budiman-Mak E, Conrad KJ, Mazza J, Stuck RM. A review of the Foot Function Index and the Foot Function Index-Revised. J Foot Ankle Res. 2013;6(1):5.
- Caravaggi P, Lullini G, Leardini A, Berti L, Vannini F, Giannini S. Functional and clinical evaluation at 5-year follow-up of a three-component prosthesis and osteochondral allograft transplantation for total ankle replacement. Clin Biomech. 2015;30(1):59–65.
- Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186–3191.
- Al-Mohrej OA, Petrisor B. Foot and ankle outcome instruments: missing the target. Curr Rev Musculoskelet Med. 2023;16(6):246–254.
Copyright (c) 2026 Immanuel M.T. Naiborhu, Iman Dwi Winanto, OK Ilham Abdullah Irsyam
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
