Fulfillment of Patient Expectations at Two Years After Elective Foot and Ankle Surgery

Category: Ankle, Ankle Arthritis, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, General foot/ankle elective procedures, outcomes Introduction/Purpose: The setting and fulfillment of expectations represent a unique aspect of patient-reported outcomes that is closely associated with satisfaction. Within foot and ankle surgery, patients may expect improvement in pain, mobility, shoe wear, and function in daily life, whether in basic activities or exercise/sports. Within foot and ankle surgery, a 23-item expectation survey has been developed based on patient responses and validated in patients undergoing elective surgery. However, to date, postoperative fulfillment of expectations has not been reported. This study aimed to describe overall rates of expectation fulfillment as well as fulfillment among specific domains. We hypothesized that patients would have the most improvement in pain and ambulation items, with greater rates of unfilled expectations for generalized items like improving confidence and returning to normal. Methods: This is a single-center study of adult patients undergoing elective foot/ankle surgery with 2-year follow-up. Demographic and clinical data were collected along with pre/postoperative Foot and Ankle Outcomes (FAOS) scores. Preoperatively, patients completed the expectations survey, citing the amount of improvement anticipated for each item using Likert-style responses. At 2 years postoperatively, patients repeated the survey, responding with the amount of improvement actually achieved. The total scores for the preoperative and postoperative surveys were used to create a ratio representing the proportion of expectations fulfilled (<1: fulfilled somewhat; 1: fulfilled as expected; >1: expectations surpassed), which was analyzed with descriptive statistics. Responses for each item (pre/postoperatively) were also assessed. Responses of “moderate,” ”a lot,” or “complete” were considered fulfilled, while ”little” or “no” indicated not fulfilled. FAOS scores were compared from baseline to follow-up using paired t-tests. Results: There were 271 patients (mean age 55.4, BMI 27.5, 65% female). Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), ankle arthritis (10%), and chronic tendon injury (9%). Patients had significant improvement in all FAOS domains (P<0.001). Mean proportion of expectations fulfilled was 1.15 (median 1.07, range 0-10), indicating surpassed expectations. Patients averaged complete fulfillment of 9 expectation items. Expectations were surpassed in 56%, met in 4%, and partially or not fulfilled in 41%. Rates of fulfillment were highest for ambulation distance, improving confidence, going back to normal, and preventing foot/ankle problem from getting worse, but did not match the level of expected improvement. Conversely, expectations were surpassed for ability to commute/drive, decreased reliance on pain medication, and participation in social/ activities. Conclusion: Overall, most patients had preoperative expectations that were met or surpassed. Though the proportion of expectations fulfilled exceeded 1, the rates of fulfillment for the most commonly cited items, especially more generalized items, were lower than expected. Improvement in ambulation ability (distance, speed, agility on uneven ground) was also lower than expected. Patients had greater improvement than expected in other functional domains (commute, social and household activities) and pain. These results may help guide appropriate management of expectations both pre and postoperatively. Future studies should assess fulfillment in the setting of specific pathologies and surgeries to better educate patients preoperatively.

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Fulfillment of Expectations after Orthopaedic Foot and Ankle Surgery: An Analysis of 271 Patients with 2-year Follow-up

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00031 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0003

Author(s):

Jensen K. Henry ◽

Andrew Roney ◽

Amelia Hummel ◽

Elizabeth Cody ◽

Scott Ellis

Keyword(s):

Roc Curves ◽

Hallux Rigidus ◽

Foot And Ankle ◽

Ankle Arthritis ◽

Patient Centered ◽

Ankle Surgery ◽

Patient Reported ◽

Outcome Tool ◽

Shoe Wear

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, General Foot/Ankle, Outcomes, Satisfaction Introduction/Purpose: Success in orthopaedic surgery was traditionally defined by postoperative radiographs or legacy outcomes scores, but increasingly incorporates more patient-centered metrics. Patient expectations are one such measure, and have been described using a new validated survey for foot/ankle patients. Understanding patients’ expectations of surgery is critical in order to facilitate shared decision-making and set reasonable goals for outcomes. In other specialties, postoperative expectations surveys have also been created and shown to correlate with measures of satisfaction and traditional patient-reported outcomes scores. However, there are no such studies in the foot and ankle literature. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. We hypothesized that the survey would significantly correlate with measures of improvement, satisfaction, and clinical outcomes scores. Methods: This is a single-center prospective study of patients undergoing elective foot and ankle procedures. Preoperative demographics, clinical data, and Foot & Ankle Outcomes Score (FAOS) were collected. Patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily functioning, exercise/sports, shoe wear, and generalized items like “improving confidence in foot/ankle” and ”going back to normal.” Postoperatively, patients answered how much improvement they received for each item listed on the preoperative survey. Using previously validated methods, the proportion of expectations fulfilled was calculated as a ratio of the preoperative to postoperative expectations score, with values of 0 -1 indicating some expectations met, 1 indicating expectations met; and >1 indicating expectations surpassed. Receiver operator characteristic (ROC) curves and areas under the curve (AUC) with 95% confidence intervals (CI) were used to compare the expectations survey to other outcomes scales, including FAOS, perceived improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. Results: 271/340 (80%) of patients with preoperative data completed 2-year follow-up (mean age 55.4 years, mean BMI 27.5, 65% female). Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), and ankle arthritis (10%). Mean proportion of expectations fulfilled was 1.15, indicating surpassed expectations. The proportion of expectations fulfilled correlated best with perceived improvement, global expectation fulfillment, and the Delighted-Terrible scale, and to a lesser degree with satisfaction and change in FAOS (all except activity). Based on the inflection point of the ROC curves corresponding to greatest AUC (Table), a clinically important proportion of expectations fulfilled was 0.81 and correlated with feeling delighted (sensitivity 0.88, specificity 0.85), improvement (sensitivity 0.89, specificity 0.83), overall expectations (sensitivity 0.91, specificity 0.81), and satisfaction (sensitivity 0.85, specificity 0.81). Conclusion: The proportion of expectations fulfilled is a valid outcome tool for foot and ankle surgery. It is uniquely able to capture pre- and postoperative data in one value and can be tailored to each patient’s specific goals. This survey can be used by surgeons after a variety of procedures to assess if a patient’s specific expectations have been fulfilled after surgery. We can use this tool to assess which patient and surgical factors may influence the fulfillment of expectations. This, in turn, will help surgeons better indicate the appropriate procedure in the optimal patient to achieve the greatest postoperative success.

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Evaluating Patients for Elective Outpatient Foot and Ankle Surgery: Insurance as a Predictor of Patient Outcomes

Foot & Ankle Specialist ◽

10.1177/1938640018823070 ◽

2019 ◽

Vol 12 (6) ◽

pp. 522-529

Author(s):

Wajeeh Bakhsh ◽

Sean Childs ◽

Irvin Oh ◽

Sam Flemister ◽

Judy Baumhauer ◽

...

Keyword(s):

Patient Selection ◽

Patient Reported Outcomes ◽

Elective Surgery ◽

Pain Patient ◽

Trauma Patients ◽

Foot And Ankle ◽

Missed Appointments ◽

Ankle Surgery ◽

Patient Reported

Background. Elective surgical procedures necessitate careful patient selection. Insurance level has been associated with postoperative outcomes in trauma patients. This study evaluates the relationship insurance level has with outcomes from elective foot and ankle surgery. Methods. Retrospective chart review was performed on patients who underwent elective surgery at a single center with 1-year follow-up. Patients were classified by insurance: under-/uninsured (Medicaid, Option plans) versus fully insured. Outcomes included narcotic refills, patient-reported outcomes (PROMIS) of pain, function, and mood, and compliance with follow-up visits. Statistical analysis involved mean comparison and multivariate regression modeling, with significance P < .05. Results. Cohort groups included 220 insured and 47 under-/uninsured. Outcomes between the insured and under-/uninsured groups differed significantly in narcotic refills (0.72 vs 1.74 respectively, P < .01), missed appointments (0.13 vs 0.62, P < .01), and PROMIS results (pain 54.5 vs 60.2; function 44.3 vs 39.5; mood 44.6 vs 51.3; P < .01). The change in PROMIS scores from preoperative to 1-year postoperative were different in pain (−7.3 vs −2.5, P = .03) and function (+6.3 vs +1.3, P = .04). Regression results confirm insurance as a significant factor (coefficient 0.27, P < .01). Conclusion. These results establish that under-/uninsured patients have worse pain, patient-reported outcomes, and functional outcomes after elective foot and ankle surgery, which may inform patient selection. Levels of Evidence: Level III: Retrospective cohort study

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Great Expectations: Predicting Postoperative Expectation Fulfillment in Orthopaedic Foot & Ankle Patients

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00046 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0004

Author(s):

Jensen K. Henry ◽

Andrew R. Roney ◽

Amelia Hummel ◽

Elizabeth Cody ◽

Carol A. Mancuso ◽

...

Keyword(s):

Short Form ◽

Tendon Injury ◽

Hallux Rigidus ◽

Foot And Ankle ◽

Postoperative Function ◽

High Expectations ◽

Ankle Surgery ◽

Patient Reported ◽

Preoperative Expectations ◽

The Relationship

Category: Other Introduction/Purpose: In foot and ankle surgery, the fulfillment of patients’ preoperative expectations is a unique and validated method to assess postoperative success. Expectation fulfillment is closely associated with postoperative outcomes, satisfaction, and patient-reported improvement. Ideally, foot and ankle patients should have realistic expectations of surgery so that they are appropriately prepared for their postoperative symptoms and function. Inappropriately high expectations may predispose to worse outcomes because patients have unrealistic views about what their surgery can actually accomplish. Conversely, inappropriately low expectations may represent a lack of motivation to improve or participate in rehabilitation and postoperative protocols. This study aimed to identify the relationship between preoperative expectations and postoperative fulfillment. These results may facilitate surgeon-patient communication and help patients prepare for their operation and their postoperative function. Methods: Adult patients undergoing elective foot and ankle surgery at a single center were prospectively enrolled. Demographics, diagnosis, and outcomes surveys (Short Form [SF]-12, Foot & Ankle Outcome Score, improvement, satisfaction) were collected. Preoperatively, each patient completed the Expectations Survey (range 0-100, with 100 indicating maximum expectations), which asks about anticipated improvement in domains like pain, ambulation, function, and shoewear. Two years after surgery, for each expectation cited preoperatively, patients answered how much improvement they actually achieved. Using a ratio of the postoperative and preoperative scores, a Fulfillment Proportion (FP) was calculated, along with the minimal clinically important difference (MCID). This permitted identification of patients with unfulfilled, fulfilled, and surpassed expectations. Bivariate correlations, chi-square analyses, and multivariate regressions with 95% confidence intervals (CI) were performed to identify the relationship between preoperative expectations, clinical variables, and postoperative expectation fulfillment. Results: There were 271/340 (80%) patients with 2-year follow-up, with mean age 55.4 years and 65% female. Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), ankle arthritis (10%), and chronic tendon injury (9%). Expectation fulfillment differed significantly with extent of preoperative expectations (Figure). Patients with average/high expectations had higher rates of unfulfillment compared to patients with low preoperative expectations (40-41% vs. 22%). Rates of surpassed expectations were highest in patients with low preoperative expectations (23%) compared to average (12%) or high (0%) preoperative expectations (p<.001). In multivariate regression, the greatest predictor of postoperative FP was the preoperative expectations score (p<.001), and lower preoperative expectations conferred a 3.2x (95% CI 1.6-6.2) greater likelihood of more expectations fulfilled (p=.001). Conclusion: Preoperative expectations were a significant predictor of expectation fulfillment after foot and ankle surgery. Lower preoperative expectations were associated with fulfilled or surpassed expectations after surgery, whereas high preoperative expectations were significantly more likely to be unmet. These findings may help guide whether patients’ expectations are realistic or inappropriate preoperatively. It is imperative for surgeons to consider and discuss patients’ expectations prior to surgery to ensure they have an appropriate understanding of their potential outcome. Further research should be directed to the extent that patients’ preoperative expectations can be modified in order to maximize postoperative satisfaction.

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Preoperative Emotional Distress Negatively Impacts Patient-reported Outcomes Following Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00068 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0006 ◽

Cited By ~ 1

Author(s):

Sandra Klein ◽

Devon Nixon ◽

Brian Cusworth ◽

Jeremy McCormick ◽

Jeffrey Johnson

Keyword(s):

Emotional Distress ◽

Patient Reported Outcomes ◽

Functional Disability ◽

Preoperative Anxiety ◽

Foot And Ankle ◽

Preoperative Pain ◽

Residual Pain ◽

Ankle Surgery ◽

Patient Reported

Category: Other Introduction/Purpose: Prior work has demonstrated that greater preoperative emotional distress leads to worse outcomes in joint arthroplasty and spine surgery. However, there is limited data on the influence of impaired preoperative psychological function on foot and ankle outcomes. Modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) can capture data such as emotional distress via the PROMIS anxiety domain. PROMIS anxiety queries symptoms of fearfulness, panic, and nervousness with scores strongly correlating to multiple legacy measures of anxiety. However, PROMIS anxiety as a surrogate for emotional distress has not been utilized in orthopedic research. We hypothesized that patients with greater preoperative emotional distress (i.e. higher PROMIS anxiety scores) would exhibit greater pain and less function than patients with lower anxiety following foot and ankle surgery. Methods: Elective foot and ankle surgeries from May 2016 – December 2016 were retrospectively identified. Patients with diabetes as well as those undergoing surgery for infection, trauma, or routine hardware removal were all excluded. PROMIS anxiety, pain interference (PI), physical function (PF), and depression scores were collected – data closest to surgery preoperatively and furthest from surgery postoperatively were used for analysis. Our study population was then grouped based on preoperative PROMIS anxiety, with scores greater than 60 indicating higher levels of emotional distress and scores below 60 indicating less impairment. A cutoff of PROMIS anxiety above 60 was selected as earlier studies have shown that threshold corresponds to clinically-significant amounts of anxiety based on traditional anxiety outcome measures. Additionally, PROMIS anxiety scores above 60 signify anxiety values one standard deviation or more away from the population average. Results: Patients with higher preoperative anxiety (average: 64.8, n=25) had greater preoperative pain and less function as compared to patients with less preoperative anxiety (average: 47.1, n=63) (PROMIS PI: 63.6 versus 59.1, P<0.01; PROMIS PF: 37.9 versus 41.7, P<0.05; respectively). Both groups of patients (i.e. high and low preoperative anxiety) demonstrated similar changes (P>0.1) in PROMIS PI and PF following surgery (? PROMIS PI: 5.1 versus 7.3;? PROMIS PF: 1.5 versus 3.0; respectively) at equivalent follow-up (5.7 versus 6.3 months, respectively). However, postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability as compared to patients with less preoperative emotional distress (PROMIS PI: 58.5 versus 51.8, P<0.001; PROMIS PF: 39.4 versus 44.7, P<0.001; respectively). Conclusion: Evidence of preoperative emotional distress – as assessed by the PROMIS anxiety instrument – predicted worse pain and function at early surgical follow-up. Detecting patients at-risk for poorer surgical outcomes remains a topic of interest in orthopedics. Our data suggest that the PROMIS anxiety tool could be useful in identifying such patients. It would be helpful, then, to counsel individuals with higher preoperative emotional distress that – despite significant improvements – residual pain and functional disability may persist after surgery. Continued surveillance will be necessary to determine if these between-group differences remain at longer-term follow-up.

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PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

Foot & Ankle International ◽

10.1177/1071100718800304 ◽

2018 ◽

Vol 40 (1) ◽

pp. 65-73 ◽

Cited By ~ 21

Author(s):

Man Hung ◽

Judith F. Baumhauer ◽

Frank W. Licari ◽

Maren W. Voss ◽

Jerry Bounsanga ◽

...

Keyword(s):

Patient Reported Outcomes ◽

Minimum Clinically Important Difference ◽

Measurement Information ◽

Diagnostic Study ◽

Foot And Ankle ◽

Meaningful Change ◽

Level Of Evidence ◽

Patient Reported ◽

Level I

Background: Establishing score points that reflect meaningful change from the patient perspective is important for interpreting patient-reported outcomes. This study estimated the minimum clinically important difference (MCID) values of 2 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Foot and Ankle Ability Measure (FAAM) Sports subscale within a foot and ankle orthopedic population. Methods: Patients seen for foot and ankle conditions at an orthopedic clinic were administered the PROMIS Physical Function (PF) v1.2, the PROMIS Pain Interference (PI) v1.1, and the FAAM Sports at baseline and all follow-up visits. MCID estimation was conducted using anchor-based and distribution-based methods. Results: A total of 3069 patients, mean age of 51 years (range = 18-94), were included. The MCIDs for the PROMIS PF ranged from approximately 3 to 30 points (median = 11.3) depending on the methods being used. The MCIDs ranged from 3 to 25 points (median = 8.9) for the PROMIS PI, and from 9 to 77 points (median = 32.5) for the FAAM Sports. Conclusions: This study established a range of MCIDs in the PROMIS PF, PROMIS PI, and FAAM Sports indicating meaningful change in patient condition. MCID values were consistent across follow-up periods, but were different across methods. Values below the 25th percentile of MCIDs may be useful for low-risk clinical decisions. Midrange values (eg, near the median) should be used for high stakes decisions in clinical practice (ie, surgery referrals). The MCID values within the interquartile range should be utilized for most decision making. Level of Evidence: Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

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Responsiveness of the PROMIS and FAAM Instruments in Foot and Ankle Orthopedic Population

Foot & Ankle International ◽

10.1177/1071100718799758 ◽

2018 ◽

Vol 40 (1) ◽

pp. 56-64 ◽

Cited By ~ 9

Author(s):

Man Hung ◽

Judith F. Baumhauer ◽

Frank W. Licari ◽

Jerry Bounsanga ◽

Maren W. Voss ◽

...

Keyword(s):

T Test ◽

Measurement Information ◽

Foot And Ankle ◽

Level Of Evidence ◽

Paired Samples ◽

Level Ii ◽

Patient Reported ◽

Prospective Comparative Study ◽

Ability Measure

Background: Investigating the responsiveness of an instrument is important in order to provide meaningful interpretation of clinical outcomes. This study examined the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), the PROMIS Pain Interference (PI), and the Foot and Ankle Ability Measure (FAAM) Sports subscale in an orthopedic sample with foot and ankle ailments. Methods: Patients presenting to an orthopedic foot and ankle clinic during the years 2014–2017 responded to the PROMIS and FAAM instruments prior to their clinical appointments. The responsiveness of the PROMIS PF v1.2, PROMIS PI v1.1, and FAAM Sports were assessed using paired samples t test, effect size (ES), and standardized response mean (SRM) at 4 different follow-up points. A total of 785 patients with an average age of 52 years (SD = 17) were included. Results: The PROMIS PF had ESs of 0.95 to 1.22 across the 4 time points (3, >3, 6, and <6 months) and SRMs of 1.04 to 1.43. The PROMIS PI had ESs of 1.04 to 1.63 and SRMs of 1.17 to 1.23. For the FAAM Sports, the ESs were 1.25 to 1.31 and SRMs were 1.07 to 1.20. The ability to detect changes via paired samples t test provided mixed results. But in general, the patients with improvement had statistically significant improved scores, and the worsening patients had statistically significant worse scores. Conclusion: The PROMIS PF, PROMIS PI, and FAAM Sports were sensitive and responsive to changes in patient-reported health. Level of Evidence: Level II, prospective comparative study.

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Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery

Foot and Ankle Surgery ◽

10.1016/j.fas.2020.02.003 ◽

2021 ◽

Vol 27 (1) ◽

pp. 52-59 ◽

Cited By ~ 1

Author(s):

Mikko M. Uimonen ◽

Ville T. Ponkilainen ◽

Alar Toom ◽

Mikko Miettinen ◽

Arja H. Häkkinen ◽

...

Keyword(s):

Patient Reported Outcome ◽

Foot And Ankle ◽

Ankle Surgery ◽

Patient Reported

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Conversion of Ankle Fusions to Ankle Replacements

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00515 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0051

Author(s):

Stephen White ◽

Bruce Cohen ◽

Carroll Jones ◽

Michael Le ◽

W. Hodges Davis

Keyword(s):

Ankle Arthrodesis ◽

Total Ankle Arthroplasty ◽

Ankle Arthritis ◽

Ankle Arthroplasty ◽

Patient Reported ◽

Fusion Site ◽

Foot Function ◽

Patient Related Outcome ◽

Improved Function

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis remains a prominent treatment choice for ankle arthritis in a majority of patients. Long term studies have shown a compensatory development of ipsilateral adjacent joint arthritis after ankle arthrodesis, and some patients who receive an ankle arthrodesis develop pain in surrounding joints, or even at the fusion site. As total ankle arthroplasty (TAA) design, instrumentation, and techniques have improved, the use of total ankle arthroplasty has become more widespread. Very few studies have been published on conversion of ankle arthrodesis to ankle arthroplasty, but they have shown improved function and patient-related outcome scores. The purpose of this study was to assess the radiographic, clinical, and patient-reported outcomes of patients undergoing ankle arthroplasty after conversion from a CT-confirmed ankle arthrodesis. Methods: This was a retrospective cohort study of patients with previous CT-confirmed ankle arthrodesis who underwent conversion to total ankle arthroplasty. Minimum follow up was 1 year. Nonunions of ankle arthrodesis were excluded. AOFAS ankle-hindfoot score, foot function index (FFI), pain, revision surgeries, complications, and patient demographics were assessed. Radiographs prior to TAA, and at latest follow-up were also reviewed. Results: 10 patients were included in the study with an average age of 54.5 years. No implants had to be revised. 1/10 (10%) patients had to undergo secondary surgery for heterotopic ossification removal. The same patient had to undergo another subsequent surgery for posterior ankle decompression. 2/10 (20%) patients had a mild talar subsidence of the TAA at latest follow-up, with no patients having tibial subsidence. Talar osteolysis was noticed in 2 patients (20%) at latest follow-up, with no patients having tibial osteolysis. Only one patient (10%) was noted to have a mild valgus alignment of TAA with no varus malalignments. All radiographic changes noted were clinically asymptomatic. The average AOFAS total score was 58 (range 23,89). The mean FFI total score was 41.9 (range 0,90). Conclusion: Conversion of ankle fusion to TAA is a challenging operation but can be a viable option for patients with ongoing pain after an ankle arthrodesis. We noted low revision rates and few complications at 1 year.

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Incidence of Venous Thromboembolism in Orthopaedic Foot and Ankle Surgeries

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00108 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0010

Author(s):

Ashish Shah ◽

Samuel Huntley ◽

Harshadkumar Patel ◽

Eildar Abyar ◽

Eva Lehtonen ◽

...

Keyword(s):

Venous Thromboembolism ◽

Elective Surgery ◽

Meta Analysis ◽

Categorical Variables ◽

Continuous Variables ◽

Foot And Ankle ◽

Improvement Program ◽

Female Sex ◽

Increased Risk ◽

Ankle Surgery

Category: Other Introduction/Purpose: Venous thromboembolism (VTE) is a rare but potentially lethal complication following orthopaedic foot and ankle surgery. Surgeons continue to debate the types of patients and procedures in which it is appropriate to use chemical thromboprophylaxis. A recent meta-analysis concluded that patients at high risk for VTE after foot and ankle surgery should receive prophylaxis, but there remains a paucity of data to elucidate which demographic or comorbidity variables are most strongly associated with development of VTE. The incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed prospectively-collected data from the National Surgical Quality Improvement Program (NSQIP) 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for four broad types of foot and ankle surgery. A total of 23,212 patients were identified and grouped by current procedures terminology (CPT) codes. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Pearson’s chi-squared test was used to compare categorical variables and Student t test was used to compare continuous variables. P-values of p<0.05 were considered statistically significant. Multivariable modelling was not possible due to the very low number of VTE cases relative to non-VTE cases. Results: The mean age at the time of surgery was 52.7±17.8 years. VTE events were documented 142 times in our sample, yielding an overall sample VTE incidence of 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15,302 cases, 0.7%), foot pathologies (28/5,466, 0.6%), and arthroscopy (2/398, 0.5%). Female sex, increasing age, obesity level, inpatient status, and non-elective surgery were all significantly associated with VTE events. Postoperative pneumonia was significantly associated with VTE development. Patients who developed a VTE stayed at the hospital after surgery significantly longer than patients without VTE (6.2 vs. 3.1 days). Patients who developed VTE also had significantly higher estimated probability of morbidity (8.0% vs. 6.0%) and mortality (2.0% vs. 1.0%) when compared to patients without VTE. Conclusion: The present study confirms that VTE events after foot and ankle procedures are rare. The data presented suggest that female sex, increasing age, higher BMI, inpatient status, and non-elective procedures are associated with increased risk for VTE after orthopaedic foot and ankle surgery. Prospective, randomized, controlled trials are necessary to definitively determine the efficacy of chemoprophylaxis and to develop evidence-based clinical practice guidelines to minimize VTE after foot and ankle procedures.

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Association Between Baseline PROMIS Scores, Patient-Provider Communication Factors, and Musculoskeletal Health Literacy on Patient and Surgeon Expectations in Foot and Ankle Surgery

Foot & Ankle International ◽

10.1177/1071100720959017 ◽

2020 ◽

pp. 107110072095901

Author(s):

Aoife MacMahon ◽

Elizabeth A. Cody ◽

Kristin Caolo ◽

Jensen K. Henry ◽

Mark C. Drakos ◽

...

Keyword(s):

Health Literacy ◽

Pain Intensity ◽

Physical Function ◽

Mental Status ◽

Patient Perceptions ◽

Pain Interference ◽

Foot And Ankle ◽

Musculoskeletal Health ◽

Ankle Surgery ◽

Patient Reported

Background: Various factors may affect differences between patient and surgeon expectations. This study aimed to assess associations between patient-reported physical and mental status, patient-surgeon communication, and musculoskeletal health literacy with differences in patient and surgeon expectations of foot and ankle surgery. Methods: Two hundred two patients scheduled to undergo foot or ankle surgery at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed Patient-Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function, Pain Interference, Pain Intensity, Depression, and Global Health. Patient-surgeon communication and musculoskeletal health literacy were assessed via the modified Patients’ Perceived Involvement in Care Scale (PICS) and Literacy in Musculoskeletal Problems (LiMP) questionnaire, respectively. Results: Greater differences in patient and surgeon overall expectations scores were associated with worse scores in Physical Function ( P = .003), Pain Interference ( P = .001), Pain Intensity ( P = .009), Global Physical Health ( P < .001), and Depression ( P = .009). A greater difference in the number of expectations between patients and surgeons was associated with all of the above ( P ≤ .003) and with worse Global Mental Health ( P = .003). Patient perceptions of higher surgeons’ partnership building were associated with a greater number of patient than surgeon expectations ( P = .017). There were no associations found between musculoskeletal health literacy and differences in expectations. Conclusion: Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with higher patient than surgeon expectations. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with. Further studies are warranted to understand how modifications in patient and surgeon interactions and patient health literacy affect agreement in expectations of foot and ankle surgery. Level of Evidence: Level II, prospective comparative series.

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