Background: The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales—rumination, magnification, and helplessness—which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI). Methods: We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon’s clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded. Results: The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination ( P=.012), magnification ( P=.006), helplessness ( P=.008), and total ( P=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores ( P=.005; P=.003; P=.006; P=.003). Conclusion: The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

Background: Resilience is the ability to recover after stressful events and has been shown to correlate with surgical outcomes. However, there has been minimal research on the impact of patient resiliency on foot and ankle surgical outcomes. This study aims to determine the predictive value of preoperative resiliency scores on surgical outcomes and investigate how this compares with the predictive value of pain scores. Methods: We conducted a retrospective review of adult patients who completed a preoperative Brief Resilience Scale (BRS) and underwent surgery between November 2019 and November 2020 with a fellowship-trained foot and ankle surgeon (N=184). Data included demographics, comorbidities, surgical details, complication and reoperation rates, pre- and postoperative opioid and benzodiazepine use, and additional patient-reported outcome measures (ie, visual analog scale [VAS], Pain Catastrophizing Scale [PCS], Pain Disability Index [PDI], Foot and Ankle Outcome Score [FAOS] pain subscale). Mean follow-up duration was 4.49 (range, 1.10-14.17) months. Results: BRS weakly correlated with decreased postoperative benzodiazepine use ( P=.007). PCS magnification ( P=.050) and helplessness ( P=.047) subscales weakly correlated with increased follow-up duration. PDI total score and most subscores significantly correlated with an increase in at least 1 of the following: follow-up duration, or postoperative opioid or benzodiazepine use. Neither the VAS nor FAOS pain subscore correlated with any outcome. PDI total score was the strongest predictor of postoperative opioid (β=0.334) and benzodiazepine (β=0.315) use. Preoperative opioid users had significantly higher PDI total score (user=39.3, nonuser=24.9; P=.012) and subscores (ie, social activity, sexual behavior, self-care, life-support activities). Conclusion: BRS is an unreliable tool for predicting outcomes in foot and ankle surgery, as it only weakly correlated with decreased benzodiazepine use. Rather, given the PDI’s strong associations with postoperative measures in this study, physicians should consider the value of preoperative PDI completion when predicting how foot and ankle surgery recipients will fare postoperatively. Level of Evidence: Level III, retrospective cohort study.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) is regarded as an increasingly accepted alternative to ankle arthrodesis in patients with ankle arthritis that have failed conservative management. While significant focus within orthopedic literature has been placed on determining various risk factors for particular outcomes, the stratification of outcomes based on sex has been insufficiently investigated. Moreover, as the number of TAAs performed continues to increase, there is a growing need to examine the effects of sex on outcomes after TAA. We sought to compare patient reported outcome measures (PROMs), ankle range of motion (ROM), and complications at multiple time points in the post-operative period after TAA as stratified by sex. Methods: undergoing TAA during the years 2013 to 2018 at a single academic institution who had minimum follow-up of two years. A total of 133 patients met inclusion criteria, comprising 55.6% males and 44.4% females. Patients were evaluated pre- operatively and at 6 months, 1-year, and 2-years post-operatively. PROMs, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, Visual Analog Scale (VAS) score, and the Short Form - 12 (SF-12) were administered, and ROM was assessed at all time points. Post-operative complications were also recorded. Student t-test were used to determine differences between the outcome measures. Eighty-nine patients received the Zimmer total ankle (39 females), whereas 44 patients (20 females) received the mobile bearing Hintegra. Results: The average age was 53.6 in the male cohort as compared to 53.8 in the female cohort (p=0.93). Both pre-operatively and at 6-months post-operative, the cohorts did not differ statistically in any of the measured outcomes. At 1-year post-operative, females had a lower SF-12 PCS score (44.1 versus 47.1, p=0.019) and less plantarflexion (20.5 versus 23.5, p=0.029) as compared to males. While both cohorts saw a significant step-wise increase in AOFAS scores between pre-operative, 6-months, and 1-year post-operative (p<0.001), the AOFAS score of the female cohort plateaued at 1-year while the male cohort continued to improve significantly (<0.015). Ultimately by 2-years post-operative, females had a statistically significant lower AOFAS score as compared to males (80.3 versus 85.4, p=0.04). Conclusion: Our results show that while both cohorts experienced significant improvement in all measured outcomes, women have lower SF-12 PCS scores and AOFAS score at 1- and 2-years post-operative, respectively, as well as less plantarflexion at 1- year post-operative with a trend towards increased complication rate after TAA. While our results add to the growing body of literature supporting TAA as a reliable means of treating ankle arthritis, our results are novel in that they were stratified and analyzed based on sex. Understanding these differences in outcomes is critically important for effectively managing expectations and treating both male and female populations.

Purpose Our goal was to determine whether state Medicaid expansion and patient insurance statuses affected access to care for ankle sprain patients. Methods Four pairs of Medicaid expanded (Kentucky, Louisiana, Iowa, and Arizona) and unexpanded (North Carolina, Alabama, Wisconsin, and Texas) states were chosen. Twelve practices from each state (N = 96) were randomly selected from the American Orthopaedic Foot and Ankle Society (AOFAS) directory and called twice to request an appointment for a fictitious 16-year-old with a first-time ankle sprain using either Medicaid insurance or Blue Cross Blue Shield (BCBS) private insurance. Results An appointment was obtained at 65.6% clinics when calling with BCBS and at 45.8% with Medicaid (P =.006). There was a significant difference in successful scheduling based on insurance status in Medicaid unexpanded states (P = .007). In all states except Iowa, there were more appointments scheduled using BCBS than with Medicaid. The 3 main reasons for appointment denial were inability to provide an insurance identification number (47.1%), insurance status (23.5%), and whether the patient was referred (17.6%). The waiting period for an appointment did not differ by Medicaid expansion or insurance statuses. Conclusion For patients with first-time ankle sprains, access to care is more difficult using Medicaid insurance rather than private insurance, especially in Medicaid unexpanded states. Level of Evidence: Level II prospective cohort study

Background This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion. Methods The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years. Results Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups. Conclusion This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection. Levels of Evidence: Level III, Retrospective cohort study