Influence of Complications and Revision Surgery on Fulfillment of Expectations in Foot and Ankle Surgery

Abstract

Background: Fulfillment of patients’ expectations following foot and ankle surgery has been previously studied, and shown to be an effective modality in assessing patient-reported outcomes (PROs). Although this assessment has been shown to correlate well with patient satisfaction and other validated PROs, the impact of postoperative complications on fulfillment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfillment of patients’ expectations. Methods: Preoperatively, patients completed a validated Foot and Ankle Expectations Survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (return to operating room for revision, deep infection). FP in patients with a complication was compared to patients who did not experience a complication. In addition, the Foot and Ankle Outcomes Score (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication: 25 major (19 revisions, 6 deep infections requiring irrigation and debridement), 4 minor (4 superficial infections requiring antibiotics), and 2 major and minor (revision and superficial infection). Average time from complication to completion of fulfillment survey was 15 (±3.6) months. The groups were similar in diagnoses. Results: Complications were associated with significantly worse FP (0.69 ± 0.45 vs 0.86 ± 0.40, P = .02). Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP ( P < .001). FAOS domains were similar between groups preoperatively; postoperatively, patients without complications had significantly higher Activities of Daily Living and Quality of Life scores ( P < .05). Demographically, there was no difference in age, sex, body mass index, Charlson Comorbidity Index, depression/anxiety, or pain management between the 2 groups. Conclusion: Our data suggests that postoperative complications following foot and ankle surgery were associated with worse patient-reported fulfillment of their operative expectations even after recovery from the initial surgery and complication. This finding is independent of preoperative expectations, and correlates with patient satisfaction with their procedure. Therefore, while patient-perceived fulfillment following foot and ankle surgery is multifactorial, the incidence of a postoperative complication negatively impacts fulfillment as well as satisfaction following surgery. Level of Evidence: Level II, prospective comparative series.

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion for Treatment of Hallux Rigidus

“…Fulfillment of operative expectations has been shown to be correlated with patient-reported outcome scores, postoperative complications, and need for revision surgery in previous studies. 3,11 Interestingly, as demonstrated by the majority of patients in our prior cheilectomy cohort, patients who are unhappy with cheilectomy may often seek care with a different surgeon, likely because of the failure to fulfill expectations. Additionally, it is possible that the patients who required conversion to fusion had greater severity of hallux rigidus at baseline and may have been poor candidates for cheilectomy.…”

Conversion of First Metatarsal-Phalangeal Joint Arthrodesis to Arthroplasty: A Case Report

“…Often, hallux MTPJ arthrodesis versus arthroplasty is a decision for primary surgical treatment. Primary hallux arthroplasty often can be converted to an arthrodesis in the event of failure and is well-described in the literature [ 11 , 13 ]. Our case described above is unique, in that an arthrodesis takedown was performed to recreate the joint and motion with the hope of decreasing some of the patient’s complaints in her forefoot.…”

“…Technical factors that contribute to surgical failure are but one dimension of clinical failure and incompletely explain the difference between expectations and fulfillment of expectation [ 11 , 13 ]. In the era of evidence-based medicine, there has been a paradigm shift in outcome assessment and redefined through patient perceptions with a clear difference in definition and expectation between patient and surgeon [ 9 , 10 ].…”