Association of Anxiety and Depression With Pain and Quality of Life in Patients With Chronic Foot and Ankle Diseases

The impact of preoperative anxiety and depression on the prognosis of patients with painful accessory navicular

OBJECTIVE

This study evaluated the clinical efficacy of modified Kidner procedures for painful accessory navicular(AN) syndrome. Furthermore, it investigated the differences between patients' pre- and post-operatively, analyzing the impact on post-operative pain and functional recovery.

METHODS

This study included 50 patients diagnosed with painful AN and treated with the modified Kidner procedure at the Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an, between May 2014 and May 2023. All patients were assessed using the Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale(VAS), and American Orthopaedic Foot & Ankle Society Midfoot Scale (AOFAS) before and after surgery. Patients were divided into two groups based on the presence of preoperative anxiety/depression symptoms. Patients without preoperative anxiety/depression were assigned to Group A, while those with preoperative anxiety/depression were assigned to Group B. The baseline data, pain, functional activity, and psychological status scores of both groups were compared, and a correlation analysis was conducted to identify factors associated with anxiety/depression.

RESULTS

Out of 50 patients with painful AN syndrome who completed follow-up, 28 exhibited symptoms of anxiety/depression preoperatively, resulting in an incidence rate of 56%.Both Group A and Group B patients showed significant improvements in all postoperative evaluation metrics compared to preoperative levels (p < 0.05), yet the overall prognosis for Group B was poorer than that for Group A.There were significant differences in the degree of improvement in pain, functional activity, and anxiety/depression between the two groups(p < 0.05).female patients had a significantly higher prevalence of anxiety than male patients (p < 0.05).

CONCLUSION

Modified Kidner surgery can significantly improve the function, pain, and psychological status of patients with painful AN.However, patients with less favorable preoperative psychological status tend to have less satisfactory outcomes.Patients with preoperative anxiety or depression symptoms experience more significant pain relief after surgery, while those without such symptoms show better functional recovery.Moreover, female patients with painful AN have a higher incidence of preoperative anxiety.Future research should further explore the impact of preoperative psychological interventions on outcomes.

Impact of psychological factors on the final clinical outcomes of patients undergoing ankle arthrodesis and ankle replacement

Objective

This study aims to analyze the impact of different surgical procedures on the prognosis and psychological state of patients with end-stage ankle arthritis (ESAA) by comparing two groups of patients with ESAA who have undergone total ankle replacement (TAR) and ankle arthrodesis (AA), and to investigate whether preoperative psychological status can alter the final clinical outcomes.

Methods

This study retrospectively collected data from 66 patients with ESAA who underwent AA surgery in the Foot and Ankle Surgery Department of Xi'an Honghui Hospital between 2016 and 2023. In July 2024, the final follow-up of patients was conducted via telephone or WeChat, with a follow-up duration of no less than 12 months. Before surgery and at the final follow-up, evaluations were conducted using the Chinese version of the Hospital Anxiety and Depression Scale (HADS), the Visual Analogue Scale (VAS) for pain (ranging from 0 to 100mm), and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. The study compared differences in pain scores, functional scores, and psychological scores between patients in the TAR and AA groups before surgery and at the final follow-up. Additionally, patients who underwent TAR and AA were further subgrouped based on the severity of their preoperative psychological status, in order to analyze the impact of preoperative psychological conditions on surgical prognosis.

Results

A total of 66 patients with ESAA completed the follow-up. At the final follow-up, both the VAS and AOFAS scores in the TAR group and the AA group showed significant improvement compared to preoperative levels. Among them, the TAR group performed better in terms of AOFAS scores, but no significant difference was observed in VAS scores between the two groups. Additionally, there was no significant difference in HADS scores between the two groups at the final follow-up. Regardless of whether they belonged to the high-HADS group or the low-HADS group, patients showed significant improvement in clinical scores compared to preoperative levels. However, at the final follow-up, the clinical scores of the high-HADS group were significantly lower than those of the low-HADS group, and the incidence of complications in the high-HADS group was also higher.

Conclusion

This study found that both TAR and AA significantly improved patients' psychology, pain, and functional activities. Both surgical methods demonstrated similar improvements in terms of final psychological status and pain relief. However, patients in the TAR group showed better ankle function and mobility. Patients with poorer preoperative psychological status had worse clinical outcomes and faced a higher risk of complications. The study indicates that both TAR and AA are effective treatment options for patients with ESAA, but poor preoperative psychological status is one of the important risk factors for poor prognosis. Therefore, when selecting a treatment approach, the patient's psychological state and needs should be fully considered, and necessary psychological interventions and postoperative rehabilitation plans should be implemented to enhance the patient's treatment outcomes and quality of life.

Association of Foot Symptoms With Decreased Time to All-Cause Mortality: The Johnston County Osteoarthritis Project

OBJECTIVE

Adults with foot symptoms (ie, pain, aching, or stiffness) may be at increased risk of reduced time to all-cause mortality. The purpose of this study was to evaluate whether foot symptoms are independently associated with all-cause mortality in older adults.

METHODS

We analyzed longitudinal data from 2613 participants from the Johnston County Osteoarthritis Project, a longitudinal population-based cohort of adults 45 years of age and older. Participants completed questionnaires at baseline to determine presence of foot symptoms and covariable status. Baseline walking speed was measured via an 8-foot walk test. To examine the association of foot symptoms with time to mortality, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression models, adjusted for potential confounders.

RESULTS

We observed 813 deaths over 4 to 14.5 years of follow-up. At baseline, 37% of participants had foot symptoms, mean age was 63 years, mean body mass index was approximately 31 kg/m2, 65% were women, and 33% were Black. Moderate to severe foot symptoms were associated with reduced time to mortality after adjustment for demographics, comorbidities, physical activity, and knee and hip symptoms (HR = 1.30, 95% CI 1.09-1.54). Importantly, this association was not modified by walking speed or diabetes.

CONCLUSION

Individuals with foot symptoms had an increased hazard of all-cause mortality compared with those with no foot symptoms. These effects were independent of key confounders and were not moderated by walking speed. Effective interventions to identify and manage at least moderate foot symptoms may reduce the risk of decreased time to mortality.

Outcome measures after foot and ankle surgery: A Systematic Review

BACKGROUND

Research on outcomes measures after foot and ankle surgery is limited and methodological quality is not always assessed. We aimed to evaluate the measurement properties of patient-related outcome measures used in patients after foot- and ankle surgery.

METHODS

A Medline, Embase and Web of Sciences systematic review was performed including dates from 2000 up to April 2022. Inclusion criteria were foot and/or ankle surgery, described outcome(s) and it's assessed measurement properties. Methodological quality assessment was performed using the NOS-scale and the COSMIN-criteria.

RESULTS

143 studies (n = 18383) were included for final review, 82 about PROMs, 61 about clinical outcomes. A total of 23 different PROMs were evaluated, with a positive result in all measurement properties for the FAOS. There were positive results too for most measurement properties of the LEFS and the MOXFQ. Most clinical outcomes were radiological measures, with a high reliability for most measurements on plain radiographs and CT-scans.

CONCLUSIONS

To monitor foot and ankle outcome and evaluate treatment, we recommend the FAOS as the most suitable foot and ankle PROM.

LEVEL OF CLINICAL EVIDENCE

2.

Visual analog scale foot and ankle (VAS-FA): Reliability and validity of the Persian version

BACKGROUND

Our purpose was to evaluate the reliability and validity of the Persian version of the visual analog scale foot and ankle (VAS-FA) among patients with foot and ankle problems and healthy subjects.

METHODS

The VAS-FA was translated and adapted into Persian (Farsi). Then, 82 participants, including 41 healthy subjects and 41 patients with foot and ankle problems, fulfilled the questionnaire in two sessions. The validity was assessed by correlating VAS-FA with the Persian version of the foot and ankle outcome score (FAOS) and the foot and ankle ability measure (FAAM). Intraclass correlation coefficient (ICC) and Cronbach's α were used to assess test-retest reliability and internal consistency.

RESULTS

There was a statistically significant difference between healthy participants and patients regarding the total VAS-FA score and its subscales (P < 0.001). The test-retest reliability was excellent, and the internal consistency was good to excellent. The correlation between the total VAS-FA score and FAAM and FAOS scores was good for the healthy subjects and good to excellent for patients.

CONCLUSION

The Persian version of VAS-FA is valid and reliable.

Depression and Anxiety in 336 Elective Orthopedic Patients

Background/Objectives: Depression and anxiety are the two most common mental health disorders that can affect the well-being of the entire body. Multiple studies confirm that they can threaten the musculoskeletal system and the effects of orthopedic treatment as well. In turn, orthopedic disorders may worsen the symptoms of depression and anxiety. The study is aimed at assessing the incidence of depressive and anxiety disorders in orthopedic patients of our department and what are the characteristics of orthopedic patients regarding depressive disorders. Methods: After obtaining personal consent for trial, 336 patients undergoing elective orthopedic surgery over a 12-month period were evaluated. Preoperatively, patients completed surveys containing questions from the PHQ-9 and GAD-7 forms. The pain was assessed with the VAS scale of 0-10 points and the information on the current psychiatric treatment was acquired. Patients were divided into subgroupsand statistical analysis was performed. Results: The incidence of moderate depression and generalized anxiety symptoms in orthopedic patients was 12.2% and 11.3%, respectively (several times higher than in the general population). In the group most at risk of depression, i.e., women over 40 and with foot and ankle diseases, the incidence of treated depression was 36%. In foot and ankle patients, prevalence for depression was more than three times higher (OR = 3.24, 95% CI 1.542-7.24) compared to the reference group. Conclusions: The problem of depression and generalized anxiety in orthopedic patients is clearly more common than in the general population. In our study, patients with foot and ankle disorders are the most vulnerable to depression.

Perioperative duloxetine improves postoperative outcomes after anterior talofibular ligament repair for chronic lateral ankle instability for patients with depression: A prospective randomized clinical trial

BACKGROUND

Recent studies have indicated that depression is associated with persistent postoperative pain and decreased satisfaction following foot and ankle surgery. This study aimed to evaluate the effect of perioperative duloxetine on postoperative outcomes of anterior talofibular ligament (ATFL) surgical repair for chronic ankle instability (CAI) in patients with depression. We further sought to evaluate patients' satisfaction and side effects related to duloxetine.

MATERIAL AND METHODS

Patients undergoing ATFL repair were screened for depression preoperatively with the Patient Health Questionnaire (PHQ-9). Among 249 patients who underwent arthroscopic or open surgical Brostrom repair of the ATFL, 120 patients were identified as being "possibly depressed" and were included in the study. Sixty patients were randomly assigned to the duloxetine group (one day preoperatively and for 6 weeks postoperatively), and the other sixty were randomized to the placebo group. Painkillers and opioid consumption, pain scores, and patient satisfaction were recorded at 12, 24, 48, and 72hours postoperatively and at follow-up visits 1, 3, and 6 months after surgery. Patient-reported outcome measures (PROMs) were assessed preoperatively and at 3, 6, 12 and 24 months postoperatively. Duloxetine-related side effects such as nausea/vomiting and fatigue were also recorded.

RESULTS

The patients in the duloxetine group reported a significantly longer time to rescue analgesic and reduced opioid requirements (including celecoxib, pregabalin, acetaminophen, and tramadol). The patients experienced decreased pain intensity and greater satisfaction with their pain management at 24, 48, 72h and 1 and 3 months after surgery (p<0.05). The duloxetine group also had significantly better clinical and functional outcomes at 3 and 6 months of follow-up compared to the placebo group (p<0.05). The occurrence and rate of symptoms of duloxetine side effects were not significant.

DISCUSSION

Depression is an important factor to consider and address because its presence before surgery can predict poor postoperative outcomes, including more severe postoperative pain, persistent postoperative pain, and increased consumption of painkillers and opioids.

CONCLUSION

Perioperative administration of duloxetine following ATFL repair for CAI in patients with depression increased the time to first postoperative rescue analgesic request and reduced both opioid consumption and postoperative pain. This approach also led to a high level of patient satisfaction. In addition, duloxetine improved the quality of recovery without leading to significant side effects.

LEVEL OF EVIDENCE

I; prospective randomized controlled trial.

Preoperative Depression is Associated With Increased Complications Following Ankle Fracture Surgery

BACKGROUND

The effects of preoperative depression following ankle fracture surgery remains unknown. The purpose of this study is to investigate the relationship between preoperative depression and outcomes following ankle fracture surgery.

METHODS

This retrospective study used the Truven MarketScan database to identify patients who underwent ankle fracture surgery from January 2009 to December 2018. Patients with and without a diagnosis of preoperative depression were identified based on International Classification of Diseases (ICD) codes. Chi-squared and multivariate analyses were performed to determine the association between preoperative depression and postoperative complications following ankle fracture surgery. Results. In total, 107,897 patients were identified for analysis, 13,981 of whom were diagnosed with depression (13%). Preoperative depression was associated with the increased odds for postoperative infection (odds ratio [OR]: 1.33, confidence interval [CI]: 1.20-1.46), wound complications (OR: 1.13, CI: 1.00-1.28), pain-related postoperative emergency department visits (OR: 1.58, CI: 1.30-19.1), 30-day and 90-day readmissions (OR: 1.08, CI: 1.03-1.21 and OR: 1.13, CI: 1.07-1.18), sepsis (OR: 1.39, CI: 1.12-1.72), and postoperative development of complex regional pain syndrome (OR: 1.46, CI: 1.18-1.81).

CONCLUSION

Preoperative depression is associated with increased complications following ankle fracture surgery. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor.

LEVEL OF EVIDENCE

3.

Differences in Baseline Physical Function and Mental Health PROM Scores in Patients With Foot and Ankle Conditions

BACKGROUND

This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated PROMIS scores and to compare the correlation between these 2 outcomes across common diagnoses. Additionally, it investigated the effects associated with chronic vs acute conditions and specific diagnoses on mental health.

METHODS

We reviewed baseline PROMIS Physical Function 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,245 patients with one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model including age, sex, language, race, ethnicity, education level, income, and Charlson Comorbidity Index was used to determine the associated effect of diagnosis on PGM score.

RESULTS

On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, whereas patients with hallux valgus had the highest (PF10a = 33.9 vs 46.7, P < .001). Patients with foot/ankle osteoarthritis had the lowest mean self-reported mental health, whereas patients with hallux rigidus had the highest (PGM = 49.9 vs 53.4, P < .001). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r = 0.511) and weakest in patients with ankle fractures (r = 0.232) or sprains (r = 0.280). Chronic conditions, including hammertoes (β = -5.1, 95% CI [-5.8, -4.3], P < .001), foot/ankle osteoarthritis (β = -5.0, 95% CI [-5.7, -4.3], P < .001), and hallux valgus (β = -4.8, 95% CI [-5.5, -4.1], P < .001) were associated with the largest negative effects on patients' mental health.

CONCLUSION

Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic conditions. The associations between diagnosis and mental health scores appear larger for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function.

Take a load off: skeletal implications of sedentism in the feet of modern body donors

Background and Objectives

Modern biocultural environments continue to place selective pressures on our skeletons. In the past century, a major cultural pressure has been the rise in sedentism. However, studies considering the effects of sedentism on the foot have largely considered pathological changes to the gross foot without particular regard for the pedal skeleton. To address this gap in the literature, temporal trends in the development of osteoarthritis and entheseal changes on the tarsals and metatarsals were analyzed in the context of biodemographic data for recent modern humans.

Methodology

The sample utilized for this project is comprised of 71 individuals from the William M. Bass Donated Skeletal Collection, with birth years ranging from 1909 to 1993. Temporal trends in osteoarthritis and entheseal changes were determined via ANCOVA, using year of birth as the explanatory variable and biodemographic variables (age, sex, stature, body mass index and tibial robusticity) as covariates.

Results

Results indicate that entheseal changes and osteoarthritis have decreased over time, and these trends are statistically significant. Temporal trends in pedal entheseal changes and osteoarthritis vary by sex.

Conclusions and Implications

The increase in sedentary behavior over time has usually been framed as a net negative for human health and well-being. However, considered in isolation, the decrease in entheseal changes and osteoarthritis presented here might be considered a positive development as they suggest overall less stress on the modern human foot. This study also has the potential to inform the health sciences and general public about biocultural contributors to modern foot health.

Two-Year Clinical and Radiologic Outcomes Following Surgical Treatment of Insertional Achilles Tendinopathy Using a Central Tendon-Splitting Approach

BACKGROUND

If conservative treatment of insertional Achilles tendinopathy (IAT) fails, surgery is often considered. Various surgical approaches have been used including the central Achilles tendon splitting approach. This study aimed to report the 2-year clinical and radiologic outcomes after surgical treatment of IAT with a central tendon-splitting approach.

METHODS

Seventy-five cases of IAT treated surgically via the open central tendon-splitting approach were analyzed. Clinical outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, all measured at baseline and 6 and 24 months postoperatively. Radiologic parameters measured included the Fowler-Philip angle (FPA) and parallel pitch lines (PPL).

RESULTS

Three patients had clinically significant wound issues but healed completely by 3 weeks. Mean AOFAS score improved from 45.63 preoperatively to 94.71 at 24 months. Mean VAS score improved from 6.73 preoperatively to 0.55, mean SF-36 PCS from 35.98 to 48.74, and mean SF-36 MCS from 53.04 to 55.43 at 24 months. Satisfaction at 2 years was 94.3%. Mean FPA decreased from 62.0 degrees preoperatively to 34.0 degrees postoperatively. PPL was positive in 82.7% (62 of 75) of cases preoperatively, decreasing to 1.3% (1 of 75) postoperatively. Increasing age and higher preoperative VAS and SF-36 MCS scores were significantly associated with improvements in postoperative AOFAS, SF-36 PCS, and MCS scores.

CONCLUSION

Surgical treatment of IAT via the central tendon-splitting approach achieved substantial improvements in all patient-reported outcome measures measured. These excellent clinical outcomes continued to show improvement 2 years postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Management of Anxiety for Ambulatory Hallux Valgus Surgery With a Virtual Reality Hypnosis Mask: Randomized Controlled Trial

BACKGROUND

The purpose of this study was to evaluate the impact of using virtual reality masks for the management of preoperative anxiety and its impact on postoperative and predischarge anxiety as well as postoperative analgesia during outpatient hallux valgus surgery.

METHODS

From June 2020 to September 2021, preoperative anxiety of patients scheduled for a percutaneous hallux valgus surgery were analyzed using the State Trait Anxiety Inventory (STAI) questionnaire completed during the consultation. All patients with major anxiety, defined as a STAI score above 40, were included in a randomized prospective comparative single-center study. Sixty patients were included in the study and randomized into 2 arms of 30 patients according to whether or not they underwent a preoperative hypnosis session with a virtual reality mask before surgery.

RESULTS

There was an improvement in the postoperative (42.5 vs 45.2, P < .04) and predischarge (25.3 vs 30.2 P < .03) anxiety scores in the group that used the mask before the procedure. There was a notable decrease in immediate higher-level postoperative analgesics such as morphine or ketamine (3.3% vs 26.6%, P < .03) in the arm using the mask.

CONCLUSION

In this study cohort undergoing percutaneous hallux valgus surgery, we found that use of a virtual reality hypnosis mask before surgery modestly reduced postoperative and predischarge anxiety as well as early postoperative consumption of higher-level analgesics in adults with significant preoperative anxiety.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Impact of pain in other body regions on the foot-specific quality of life in patients with hallux valgus

OBJECTIVES

The purpose of this study was to clarify the prevalence of pain outside the foot, and to determine the associations of pain outside the foot with foot-specific quality of life (QOL) in patients with hallux valgus.

METHODS

Patients scheduled to undergo hallux valgus surgery were recruited. Patients answered whether they experienced disabling pain in 13 body regions other than the foot. Foot-specific QOLwas assessed using the Self-Administered Foot Evaluation questionnaire (SAFE-Q). Foot pain was quantified using the visual analogue scale (VAS). Patient characteristics, including age, sex, comorbidity, anxiety, and depression, were also surveyed. The association between pain elsewhere and the SAFE-Q and pain VAS scores were assessed using univariate and multivariate analyses.

RESULTS

Of 102 patients, 55 (54%) experienced pain other than the foot. All SAFE-Q subscale scores were lower, and pain VAS was higher in patients with pain elsewhere than in patients without. In the multivariate analysis, an increase in the number of pain regions was independently associated with a decrease in SAFE-Q scores and an increase in pain VAS.

CONCLUSION

More than half of the patients with hallux valgus experienced pain elsewhere. The presence of pain elsewhere was associated with poorer foot-specific QOL and severer foot pain.

Musculoskeletal Pain Management and Patient Mental Health and Well-being

Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.

Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care

OBJECTIVES

To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care.

DESIGN

Retrospective case series.

SETTING

Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019.

PATIENTS

All patients presenting to the practice during 2019 were included (n = 573).

INTERVENTION

We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway.

MAIN OUTCOME MEASUREMENTS

The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected.

RESULTS

Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room.

CONCLUSIONS

This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.

Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty

INTRODUCTION

Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship.

METHODS

This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data.

RESULTS

Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68).

DISCUSSION

Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies.

LEVELS OF EVIDENCE

Prognostic, Level III: Comparative study.

Anxiety, Depression, Chronic Pain, and Quality of Life Among Older Adults in Rural China: An Observational, Cross-Sectional, Multi-Center Study

PURPOSE

To determine the incidence of anxiety and depression and examine their cross-sectional associations with chronic pain and quality of life among older adults in rural China.

DESIGN

Observational, multi-center, cross-sectional study.

METHODS

A structured, self-report questionnaire was administered. Descriptive statistics analysis and stepwise multiple linear regression analysis were performed.

FINDINGS

244 participants (female: 47.1%) filled out the questionnaires. 87 (35.7%) had symptoms of anxiety and 123 (50.4%) had symptoms of depression. The sensory pain descriptor, affective pain descriptor, physical component summary, and mental component summary significantly influenced symptoms of anxiety while affective pain descriptor, physical component summary, and mental component summary significantly influenced symptoms of depression.

CONCLUSION

Subjective pain experiences and QoL, including physical and mental domains, are strongly related to symptoms of anxiety and depression among older adults in rural China.

CLINICAL EVIDENCE

Interventions that highlight subjective pain experiences and QoL may help to relieve symptoms of anxiety and depression in older adults.

Validity and reliability of the Persian version of self-administered foot evaluation questionnaire (SAFE-Q) in people with foot orthopedic problems

INTRODUCTION

Foot problems are one of the main causes of seeing a doctor. According to the World Health Organization's definition of health, the healthcare system must consider patients' quality of life as an important entity. In this regard, many tools have been developed to evaluate patients' opinions about their health status. The purpose of the present study is to evaluate the validity and reliability of the Persian version of the Foot Self-Assessment Questionnaire (SAFE-Q) in patients with foot orthopedic problems.

METHOD

215 people aged 17-60 years with orthopedic foot problems were included in this cross-sectional study. The Spearman correlation coefficient of SAFE-Q questionnaires versus Foot Function Index (FFI) questionnaire was evaluated for the convergent validity. Forty-three people randomly completed SAFE-Q again one week later. Intraclass correlation coefficient (ICC) and Cronbach's alpha was calculated to evaluate the test-retest reliability and internal consistency of the SAFE-Q, respectively.

RESULTS

A strong relationship was found between the SAFE-Q total score and other scales with FFI questionnaire (r = 0.52 to 0.87). ICC test-retest reliability and Cronbach's alpha were 0.981 and 0.98 for SAFE-Q, respectively.

CONCLUSION

The results indicate that the Persian version of the SAFE-Q questionnaire has acceptable validity and reliability and can be used to assess the health status and quality of life of Persian speakers with orthopedic foot problems.

Complications of Lesser Toe Surgery: How To Avoid Them before Surgery and How To Assess and Treat Them When They Have Occurred

Complications following lesser toe surgery are challenging to manage. The keys to treatment of any of these conditions are, first, to try to avoid them through identification of patient- and surgeon-related variables that contribute to their development and, second, following the occurance of a complication, to understand what can and cannot be corrected with surgical and nonsurgical management. This review provides a comprehensive assessment of current literature, demonstrates best practices and approaches to lesser toe complications, and provides an illustration of clinical examples.

Evaluation and Validation of the Dutch European Foot and Ankle Society (EFAS) Score

The European Foot and Ankle Society (EFAS) score is a recently developed foot and ankle patient-reported outcome measure. It has been developed and partly validated in seven languages. This study's aim was to investigate the measurement properties of the Dutch version of the EFAS score. Subscales of the Dutch EFAS score were evaluated in 547 patients with a variety of foot and ankle diagnoses. Floor and ceiling effect, reliability, and construct validity were assessed. The internal consistency of the EFAS score was acceptable (Cronbach's alpha 0.79-0.94). Repeatability was considered poor, with intraclass correlation coefficients between 0.32 and 0.39. Construct validity was inadequate with confirmation of 67% of the hypothesized correlations. In conclusion, the Dutch version of the EFAS score does not have adequate measurement properties for use in patient with patients with varying foot and ankle problems.

Pain catastrophising, body mass index and depressive symptoms are associated with pain severity in tertiary referral orthopaedic foot/ankle patients

Introduction

Patients with chronic foot/ankle pain are often referred for orthopaedic assessment. Psychological vulnerabilities influence pain states (including foot and ankle), therefore this study aimed to establish the prevalence and relative importance of compromised psychological health to perceived foot/ankle pain severity in people referred to an orthopaedic foot and ankle clinic with non-urgent presentations.

Methods

Patients with triaged non-urgent foot/ankle referrals to the Department of Orthopaedics at Gold Coast University Hospital were recruited over a 12-month period and completed the Manchester-Oxford Foot and Ankle Questionnaire which was the primary measure. Participants also completed questionnaires assessing their anthropometric, demographic and health characteristics (Self-Administered Comorbidity Questionnaire) as well as measures of health-related quality of life (EuroQol-5-Dimensions-5-Level Questionnaire and EQ Visual Analogue Scale) and psychological health (Center for Epidemiological Studies-Depression scale, Pain Catastrophizing Scale and Central Sensitization Inventory). Descriptive statistics were used to summarise participant characteristics and a hierarchical multiple linear regression was employed to establish the extent to which psychological variables explain additional variance in foot/ankle pain severity beyond the effects of participant characteristics (age, sex, body mass index (BMI)).

Results

One hundred and seventy-two adults were recruited ((64.0% female), median (IQR) age 60.9 (17.7) years and BMI 27.6 (7.5) kg/m²). Specific psychological comorbidities were prevalent including depressive symptoms (48%), central sensitisation (38%) and pain catastrophising (24%). Age, sex and BMI accounted for 11.7% of the variance in MOXFQ-index and psychological variables accounted for an additional 28.2%. Pain catastrophising was the most significant independent predictor of foot/ankle pain severity (accounting for 14.4% of variance), followed by BMI (10.7%) and depressive symptoms (2.3%).

Conclusions

This study demonstrated that specific psychological comorbidities and increased BMI are common in this cohort and that these factors are associated with the symptoms for which patients are seeking orthopaedic assessment. This knowledge should prompt clinicians to routinely consider the psychosocial components of patient presentations and develop non-operative and pre-operative treatment strategies which consider these factors with the goal of improving overall patient outcomes.

Opioid use among patients with pain syndromes commonly seeking surgical consultation: A retrospective cohort

BACKGROUND

Surgeons often see patients with pain to exclude organic pathology and consider surgical treatment. We examined factors associated with long-term opioid therapy among patients with foot/ankle, anorectal, and temporomandibular joint pain to aid clinical decision making.

METHODS

Using the IBM MarketScan® Research Database, we conducted a retrospective cohort analysis of patients aged 18-64 with a clinical encounter for foot/ankle, anorectal, or temporomandibular joint pain (January 2007-September 2015). Multivariable logistic regression was used to estimate adjusted odds ratios for factors associated with long-term opioid therapy, including age, sex, geographic region, pain condition, psychiatric diagnoses, and surgical procedures in the previous year.

RESULTS

The majority of the cohort of 1,500,392 patients were women (61%). Within the year prior to the first clinical encounter for a pain diagnosis, 14% had an encounter for a psychiatric diagnosis, and 11% had undergone a surgical procedure. Long-term opioid therapy was received by 2.7%. After multivariable adjustment, older age (age 50-64 vs. 18-29: aOR 4.47, 95% CI 4.24-4.72, p < 0.001), region (South vs. Northeast, aOR 1.76, 95% CI 1.70-1.81, p < 0.001), recent surgical procedure (aOR 1.83, 95% CI 1.78-1.87, p < 0.001), male sex (aOR 1.14, 95% CI 1.12-1.16, p < 0.001) and recent psychiatric diagnosis (aOR 2.49, 95% CI 2.43-2.54, p < 0.001) were independently associated with long-term opioid therapy.

CONCLUSION

Among patients with foot/ankle, anorectal, or temporomandibular joint pain, the risk of long-term opioid therapy significantly increased with older age, recent psychiatric diagnoses and surgical history. Surgeons should be aware of these risk factors in order to make high quality clinical decisions in consultations with these patients.

Association of Depression and Anxiety With Expectations and Satisfaction in Foot and Ankle Surgery

INTRODUCTION

Mental health diagnoses involving depression or anxiety are common and can have a dramatic effect on patients with musculoskeletal pathologies. In orthopaedics, depression/anxiety (D/A) is associated with worse postoperative patient-reported outcomes. However, few studies have assessed the effect of D/A on expectations and satisfaction in foot and ankle patients.

METHODS

Adult patients undergoing elective foot and ankle surgery were prospectively enrolled. Preoperatively, patients completed the eight-item Patient Health Questionnaire Depression Scale, Generalized Anxiety Disorder Screener-7, Foot and Ankle Outcome Score (FAOS), and Expectations Survey. At 2 years postoperatively, surveys including satisfaction, improvement, and fulfillment of expectations were administered. Fulfillment of expectations (fulfillment proportion) and FAOS scores were compared between patients with D/A and non-D/A patients.

RESULTS

Of 340 patients initially surveyed, 271 (80%) completed 2-year postoperative expectations surveys. One in five patients had D/A symptoms. Preoperatively, D/A patients had greater expectations of surgery (P = 0.015). After adjusting for measured confounders, the average 2-year postoperative fulfillment proportion was not significantly lower among D/A compared with non-D/A (0.86 versus 0.78, P = 0.2284). Although FAOS scores improved postoperatively for both groups, D/A patients had significantly lower preoperative and postoperative FAOS scores for domains of symptoms, activity, and quality of life (P < 0.05 for all). D/A patients reported less improvement (P = 0.036) and less satisfaction (P = 0.005) and were less likely willing to recommend surgery to others (P = 0.011).

DISCUSSION

Patients with D/A symptoms had higher preoperative expectations of surgery. Although D/A patients had statistically similar rates of fulfillment of expectations compared with non-D/A patients, they had markedly lower FAOS scores for domains of symptoms, activity, and quality of life. D/A patients also perceived less improvement and were more often dissatisfied with their outcomes. These findings should not dissuade providers from treating these patients surgically but rather emphasize the importance of careful patient selection and preoperative expectation management.

LEVEL OF EVIDENCE

Level III; retrospective review of prospective cohort study.

Can patients with psychological distress achieve comparable functional outcomes and satisfaction after hallux valgus surgery? A 2-year follow-up study

BACKGROUND

This study assessed the influence of preoperative mental health on functional outcomes and satisfaction, and the change in mental health after hallux valgus surgery.

METHODS

383 patients who underwent scarf osteotomy were analyzed. Visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society score (AOFAS) and SF-36 were assessed at 6 months and 2 years. The cohort was stratified into patients with and without psychological distress (i.e. SF-36 Mental Component Summary [MCS] <50 vs ≥50).

RESULTS

After adjusting for demographics and baseline scores, VAS and AOFAS were poorer in the distressed group at 6 months. However, there was no difference in scores at 2 years and a similar proportion of patients were satisfied. SF-36 MCS in distressed patients significantly improved, but remained lower compared to non-distressed patients at follow-up.

CONCLUSIONS

Patients with psychological distress undergoing hallux valgus surgery had poorer short-term outcomes, but these differences resolved at 2 years.

Patient-Perceived Recovery and Outcomes after Bipolar Radiofrequency Controlled Ablation with Platelet-Rich Plasma Injection for Refractory Plantar Fasciosis

Previous studies have documented persistent postoperative symptoms and limitations following plantar fasciotomy using patient-reported outcome measures (PROMs). The incomplete recovery (resolution) has been theorized to occur from altered foot biomechanics, and alternative treatment methods have continued to gained popularity for addressing refractory plantar fasciosis (RPF). The purpose of the present study was to assess patient-perceived recovery (PPR) and outcomes after bipolar radiofrequency controlled ablation (BRC) with platelet-rich plasma (PRP) injection for RPF. From July 2006 to July 2016, 43 patients (52 procedures) were enrolled. PROMS were prospectively obtained and compared between patients who perceived themselves as recovered without/residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure were recorded. Overall, 67.4% perceived themselves as recovered-resolved, 23.3% as recovered-not resolved, and 9.3% as not recovered. Holistic and procedure specific satisfaction were high (90.7% and 88.4%), with a mean modified Foot Function Index of 11.65, visual analog scale for pain 1.5, and failure rate of 9.3% at a median of 53 months (interquartile range 33 to 83). In the present study, outcomes with BRC with PRP injection compared favorably to the long-term outcomes reported for partial and complete plantar fasciotomy. Although 14 patients (32.6%) continued to have some postoperative symptoms, 71% indicated that they were satisfied with their symptoms, and 64% would undergo a similar procedure again. Therefore, despite the study's shortcomings, a patient's ability to cope appears to have a role in recovery from RPF.

Identification of factors associated with social dysfunction in patients with heart failure

AIMS

Social dysfunction is adversely associated with individuals' physical and mental quality of life. However, little is known about the status of social dysfunction and its associated factors in patients with heart failure. Our study aimed to reveal the prevalence of social dysfunction, and the associations between fatigue, dyspnoea, anxiety, depression, social connectedness, and social dysfunction in patients with heart failure.

METHODS AND RESULTS

We assessed the social dysfunction, fatigue, dyspnoea, anxiety, depression, and social connectedness using self-report questionnaires among 291 patients (64.13 ± 11.84 years, 53.3% male) with heart failure. Two stepwise forward logistic regression models were employed to identify the factors associated with social dysfunction, and the area under receiver operating characteristic curve was used to calculate the variance of the associated factors accounting for social dysfunction. Of the 291 patients, 76.6% reported social dysfunction. The logistic regression model after adjusting co-variables showed that fatigue [odds ratio (OR) 4.233, 95% confidence interval (CI) 1.778-10.081], dyspnoea (OR 0.866, 95% CI 0.756-0.991), depression (OR 1.173, 95% CI 1.037-1.328) were positively associated with social dysfunction, whereas social connectedness (OR 0.394, 95% CI 0.203-0.764) was negatively associated with social dysfunction. Four factors explained 84.5% of the variance of social dysfunction in patients with heart failure.

CONCLUSIONS

Social dysfunction is prevalent in patients with heart failure, and fatigue, dyspnoea, depression, and social connectedness are the associated factors. The findings indicate that the key to helping heart failure patients return to social life may be to attenuate fatigue, dyspnoea, and depression and to improve social connectedness.

Comparative analysis of anxiety and depression prevalence between individuals with and without inflammatory bowel disease

Rationale Inflammatory bowel diseases − Crohn's Disease (CD) and Ulcerative Colitis (UC) − are chronic disorders associated, for several reasons, with psychological symptoms and stigmatization of patients.

Aim To compare individuals with and without inflammatory bowel diseases in relation to the prevalence of anxiety and depression.

Method The psychological aspect was analyzed using two globally validated questionnaires − the Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder questionnaire (GAD-7) − in addition to a sociodemographic questionnaire. Data collection was carried out in three groups, each one consisting of 100 individuals; the first comprising outpatients with a diagnosis of inflammatory bowel diseases, the second comprising outpatients without a diagnosis of inflammatory bowel diseases and the third by non-outpatients without a diagnosis of inflammatory bowel diseases.

Results The groups were similar regarding gender, ethnicity, marital status and tobacco use. As for social class, the IBD group showed a predominance of class E (46%), the outpatient group a predominance of class D (44%) and the non-outpatient group, class C (44%) (p < 0.001). The non-outpatient group also had a higher number of young individuals (mean = 36.69 years) (p < 0.001). There was a higher number of individuals with depression and anxiety in the IBD and outpatient control groups when compared to the non-outpatients’ group (p < 0.001), but with no difference between the two first groups. There was a higher number of individuals with severe degree anxiety in the IBD group (36%) compared to the non-outpatients’ group (8%) (p < 0.001).

Conclusion Greater severity and a prevalence of anxiety and depression were observed in the group with inflammatory bowel diseases.

Foot Health Assessment and Problem Identification in a Dominican Batey Community: A Descriptive Study

PURPOSE

Foot problems can adversely impact foot function and quality of life. Foot problems are often overlooked, particularly in populations with limited health care access. Little is known about the foot health of Haitian immigrants who live and work in the bateyes (rural sugarcane villages) of the Dominican Republic. These immigrant workers may experience foot problems that could affect foot function and the ability to work and provide for their families.

DESIGN

Cross-sectional, exploratory, descriptive study design.

SUBJECTS AND SETTING

A convenience sample of adults was recruited from an ongoing community-based participatory research project evaluating a mobile hypertension screening and treatment clinic program in 11 Dominican batey communities.

METHODS

Foot health was assessed using the Foot Problems Checklist, a 24-item survey instrument developed for this study based on a review of the literature and foot clinician expertise. A certified foot care nurse recorded foot health data on the Foot Problems Checklist via visual and physical inspection.

RESULTS

Study participants were 25 females and 16 males, aged 18 to 90 years, and all had at least one foot health problem. The most common foot problems were calluses (78%), dry skin (76%), thick nails (59%), jagged nails (29%), long/overgrown nails (17%), and skin fissures (12%).

CONCLUSIONS

While the foot problems we observed were not considered serious, they could become progressively debilitating and be prevented with proper self-management guided by appropriate knowledge and skills and available supplies. We recommend the development and testing of foot care self-management interventions deliverable via mobile clinics to increase access and improve foot health outcomes.

A Novel Technique of Arthroscopic Ankle Lateral Ligament Repair Using a Knotless Suture Anchor

Background:

Although arthroscopic lateral ligament repair (ALLR) with suture anchors for chronic lateral ankle instability has become widely accepted, some complications have been reported as well. Establishment of a new technique is essential for better clinical outcomes after ALLR.

Purpose

To report a novel technique and good clinical results of ALLR using a knotless suture anchor.

Study Design:

Case series; Level of evidence, 4.

Methods:

We examined 30 patients (16 men and 14 women) who underwent ALLR. The mean age of the patients was 30.0 years, and the average period of postoperative monitoring was 21 months. The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale was used for clinical evaluation postoperatively, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) for patient-reported results. Surgical complications were also examined.

Results:

The JSSF ankle-hindfoot scale showed a significant improvement from preoperatively to follow-up (from 72.1 to 96.1; P < 0.001), and the SAFE-Q was significantly improved in all subscales (pain and pain-related, physical function and daily living, social function, shoe-related, and general health and well-being; P < 0.004 for all). Complications included residual joint pain due to remaining osteophytes in 1 case, scar pain of the accessory anterolateral portal in 2 cases, and positive Tinel sign indicative of superficial peroneal nerve irritation at the anterolateral portal in 1 case.

Conclusion:

The clinical results of the novel ALLR technique were overall satisfactory. Knot-related complications, one of the main reasons for postoperative complications, were reduced by using a knotless suture anchor.

Chronic Knee and Ankle Pain Treatment through Selective Microsurgical Approaches: A Minimally Invasive Option in the Treatment Algorithm for Refractory Lower Limb Pain

BACKGROUND

 Injury or compression of a sensory nerve is an under-reported source of disabling pain in the lower limb. It is known that peripheral nerve microsurgeons can reconstruct and rewire injured nerves to relieve chronic pain but this option remains not completely understood and ignored by most orthopaedic surgeons, neurologists, and pain therapists. In this paper, we describe our experience with knee and ankle peripheral nerve surgery to improve the condition of patients suffering from chronic, posttraumatic lower limb pain.

PATIENTS AND METHODS

 Between 2015 and 2018, a retrospective investigation was performed including patients who underwent ankle and knee nerve surgery for posttraumatic chronic pain with at least 1 year of follow-up. Previous surgeries or type of trauma, pain location and characteristics, type of operation (reconstruction, decompression, or denervation), and number of nerves operated were listed. Selective neuropathy was confirmed by ultrasound-guided nerve blocks. Outcome was assessed combining the visual analogue scale (VAS) score at rest and during movement, functional indexes, drug use, and ability to work.

RESULTS

 A total of 34 patients (14 knee and 20 ankle) were included in this study. A statistically significant difference (p < 0.05%) in postoperative pain at rest and during activity was seen in both groups of patients. Good to excellent outcomes were recorded in 92 and 80% of patients treated, respectively, at the knee and the ankle levels. No major complications occurred, while a secondary procedure due to neuroma recurrence was necessary in seven patients (three knees and four ankles).

CONCLUSION

 Peripheral nerve microsurgery is a useful and minimally invasive tool to be added in the algorithm of treatment of chronic knee and ankle pain. Physicians should be trained to suspect a neuropathic origin of pain in absence of musculoskeletal signs of pathology, especially following trauma or surgeries.

Relationship of Press Ganey Satisfaction and PROMIS Function and Pain in Foot and Ankle Patients

BACKGROUND

Patient satisfaction has garnered interest as a tool to measure health care quality. However, orthopedic studies in total joint arthroplasty, spine, and hand patients have offered conflicting relationships between Press Ganey (PG) satisfaction metrics and patient-reported outcome (PRO) measures. No prior study has assessed the relationship between PG and PROs in foot and ankle patients. Whether satisfaction and outcomes instruments, though, measure similar or differing aspects of the patient experience is unclear. Here, we tested if there was an association between Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes and PG satisfaction scores.

METHODS

PG and PROMIS outcomes data for new patient visits to an orthopedic foot and ankle clinic between 2015 and 2017 were retrospectively analyzed. Patients that completed PG satisfaction surveys were included for study. All patients who completed PG surveys and completed one or both PROMIS physical function (PF) or pain interference (PI) metrics administered by computerized adaptive testing were included. Negative binomial regressions were used to compare PRO scores to PG overall satisfaction and PG satisfaction with care provider, adjusting for patient characteristics. Results were reported as dissatisfaction score ratios, which represented the amount of PG dissatisfaction associated with a 10-point increase in PROMIS PF or PI. Of the 3984 new patient visits, only 441 completed the PG survey (11.3% response rate).

RESULTS

Ceiling effects were seen with PG data: 64% of patients reported perfect satisfaction with care provider and 27% had perfect overall satisfaction. Higher function on the PROMIS PF was weakly associated with increased overall satisfaction (ratio = 0.82, 95% CI: 0.68-0.99, P = .039) and increased satisfaction with care provider (ratio = 0.60, 95% CI: 0.40-0.92, P = .019). However, pain (PROMIS PI) was not associated with overall satisfaction or with satisfaction with care provider.

CONCLUSIONS

Based on our data here, patient satisfaction was weakly related to patient-reported function but not pain interference among this subset of new patients presenting to a foot and ankle clinic. Given our essentially negative findings, further study is needed to determine which aspects of the PG satisfaction and PROMIS scores track similarly. Further, our findings add to the growing literature showcasing limitations of the PG tool, including low response rates and notable ceiling effects. If satisfaction metrics and patient-reported outcomes capture differing aspects of the patient experience, we need to better understand how that influences the measurement of health care quality and value.

LEVEL OF EVIDENCE

Level III, comparative study.

Effect of Psychotropic Medications on Hammertoe Reconstruction Outcomes

Background:

Hammertoe deformities can seriously affect activity level and footwear. The use of prescription, mood-altering medications is very common, with some estimates as high as 25% of the population. Mood disorders, especially depression, negatively affect the results of medical and operative treatments. This study assessed the relationship of mood-altering medication use with the outcomes and complications of operative reconstruction of hammertoes.

Methods:

Data were prospectively collected from 116 patients who underwent hammertoe reconstruction, including demographic information, medical history, the use of mood-altering psychotropic medications (antidepressants, anxiolytics, hypnotics, and mood stabilizers), and postoperative complications. Preoperative patient-reported outcomes were measured using the visual analog scale (VAS) for pain and Short Form Health Survey (SF-36), which were repeated at 1-year follow-up.

Results:

A total of 36.2% of patients were taking psychotropic medications. Medication and nonmedication groups had similar pain VAS and SF-36 Physical Component Summary (PCS) scores before and after surgery. Compared with nonmedication patients, patients on psychotropic medications had significantly lower SF-36 Mental Component Summary (MCS) scores preoperatively (P = .001) and postoperatively (P = .006), but no significant difference in the change in MCS (ΔMCS) from preoperative to postoperative. Psychotropic medication use was associated with superficial wound infections (P = .048), but not other complications.

Conclusions:

Patients taking psychotropic medications were equally likely to benefit from forefoot reconstruction as nonmedication patients. Preoperative and postoperative PCS and VAS were not significantly different between medication and nonmedication groups. Although the medication group had lower absolute MCS, they reported the same magnitude of improvement in MCS (ΔMCS) as the nonmedication group.

Level of Evidence:

Level II, prospective cohort study.

Combined analysis of 3 cross-sectional surveys of pain in 14 countries in Europe, the Americas, Australia, and Asia: impact on physical and emotional aspects and quality of life

Background and aims

Recognition of the biopsychosocial aspects of pain is important for a true understanding of the burden of pain and the necessity of pain management. Biopsychosocial aspects of pain may differ between countries and cultures. Market research methods can be well suited and effective for assessing patient perspectives of pain and biopsychosocial differences. We conducted and combined 3 cross-sectional, international surveys to document the impact of pain on physical and emotional aspects of life, as well as quality of life (QOL).

Methods

Online panelists from 24 countries took part in our surveys in 2014, 2016, and 2017. Fourteen countries (Australia, Brazil, Canada, China, Germany, Italy, Japan, Poland, Russia, United Kingdom, United States, Mexico, Sweden, Saudi Arabia) contributed data in all 3 surveys and comprise the analysis population. A Global Pain Index (GPI) was constructed using 8 questions in 3 categories: Physical (frequency, duration, intensity of pain), Emotional (anxiety, impact on self-esteem, happiness), and Impact on QOL and ability to enjoy life. Each item was scored as the percentage of respondents meeting a prespecified threshold indicative of a substantial pain impact. Scores for the items within each category were averaged to obtain a category score, category scores were averaged to obtain a total score for each survey, and total scores from each survey were averaged to obtain a final combined score. Scores were assessed for the overall population, by individual countries, by age and gender, and by self-identified pain-treatment status (treat immediately, wait, never treat).

Results

Of the 50,952 adult respondents, 28,861 (56.6%) had ever experienced musculoskeletal pain; 50% of those with pain had pain with a multifaceted impact based on the GPI (Physical: 51%; Emotional: 40%; QOL Impact: 59%). Russia (57%) and Poland (56%) had the highest scores; Mexico (46%), Germany (47%), and Japan (47%) had the lowest. GPI score was higher in women (52%) than men (48%), and initially increased with age through age 54 (18‒24 years: 45%; 25‒34 years: 52%; 35‒44 years: 53%; 45‒54 years: 54%), after which it decreased again (55‒64 years: 51%; ≥65 years: 45%). A majority (65%) of respondents wait to treat their pain, whereas 21% treat their pain immediately and 14% never treat pain. The most common reason for waiting (asked in survey 3 only) was to avoid taking medication.

Conclusions

In this combined analysis of 3 international surveys using a novel biopsychosocial pain assessment tool, pain had a substantial impact on ~50% of respondents’ lives, spanning physical (51%), emotional (40%), and QOL effects (59%). Despite the substantial impact, a majority of patients tried to avoid treating their pain.

Implications

Clinicians should take a biopsychosocial approach to pain by asking patients not only about the presence and severity of pain, but the extent to which it affects various aspects of their lives and daily functioning. Patients may also need education about the efficacy and safety of available treatments for self-management of pain. The GPI may be a useful new tool for future studies of the biopsychosocial effects of pain in large populations.

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.

Preoperative Anxiety Effect on Patient-Reported Outcomes Following Foot and Ankle Surgery

BACKGROUND

Preoperative emotional distress has been shown to negatively influence joint arthroplasty and spine surgery, but limited data exist for foot and ankle outcomes. Emotional distress can be captured through modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) anxiety domain. We hypothesized that patients with greater preoperative PROMIS anxiety scores would report greater pain and less function after foot and ankle surgery than patients with lower preoperative anxiety levels.

METHODS

Elective foot and ankle surgeries from May 2016 to December 2017 were retrospectively identified. PROMIS anxiety, pain interference (PI), and physical function (PF) scores were collected before and after surgery. Patients were grouped based on preoperative PROMIS scores greater or less than 59.4. A cutoff of PROMIS anxiety above 59.4 was selected as the threshold that corresponds to traditional measures of anxiety.

RESULTS

Compared to patients with less preoperative anxiety (average: 47.2, n=146), patients with higher preoperative anxiety (average: 63.9, n=59) had greater preoperative pain (PROMIS PI: 63.5 vs 59.1, P < .001) and lower physical function (PROMIS PF: 37.9 vs 42.0, P = .001). 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: 58.6 vs 52.9, P < .001; PROMIS PF: 39.8 vs 44.4, P < .001; respectively).

CONCLUSION

Our evidence showed that preoperative emotional anxiety predicted worse pain and function at early operative follow-up. Measures of preoperative anxiety could be useful in identifying patients at risk for poorer operative outcomes, but continued study is necessary.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Osseous Metastatic Disease to the Hands and Feet

Osseous metastases to the hands and feet (acrometastases) are exceedingly rare. Historically, the most common primary cancer observed has been lung carcinoma, treated either nonoperatively or with amputation. The aim of this study was to describe the clinical characteristics associated with acrometastases. This was a retrospective review of 28 patients with histologically proven osseous metastatic disease to the hands and feet. Variables recorded included primary cancer histology, age at diagnosis of primary and acrometastases, location of acrometastases, burden of disease, treatment, and age at death. Kaplan-Meier curves were used to estimate survival, and log-rank tests were used for comparison. The median age at acrometastases diagnosis was 61.5 years, and the most common associated primary cancer was lung carcinoma (n=9). Sixteen patients had acrometastases to the foot, and 12 had acrometastases to the hand. In the foot, most acrometastases were located in the tarsal bones (n=11), followed by the metatarsals (n=4) and the phalanges (n=3). In the hand, most were in the metacarpals and the phalanges (n=6 each), and 2 were in the carpals. The most common treatment was resection or curettage only (n=7). The median duration of survival after acrometastases diagnosis was 9.7 months. Despite advances in cancer treatment and shifting patterns of metastatic disease, there has been little change in the distribution of primary malignancies responsible for acrometastases, with lung carcinoma remaining the most common. Ablative procedures are rarely required, with limb-salvage interventions predominating. [Orthopedics. 2019; 42(2):e197-e201.].

Patient-Perceived Recovery and Outcomes After Silastic Implant Arthroplasty

In some chronic musculoskeletal conditions, patients with persistent pain and disability have still achieved recovery through behavioral adaptations (readjustment) or cognitive coping (redefinition). Although the pendulum shift from physician-reported clinical indicators to patient-reported outcomes measures (PROMs) has recently focused on quantifying residual pain and disability to determine recovery (resolution), whether patients are capable of coping with any ongoing deficits and achieving other forms of recovery has not been considered. We performed a retrospective case series to assess patient-perceived recovery and outcomes after silastic implant arthroplasty for hallux rigidus. From July 2006 to July 2016, 28 patients at a single institution were enrolled. PROMs were prospectively obtained and compared between patients considering themselves recovered without or with residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure rates were recorded. Overall, 50.0% perceived themselves as recovered-resolved, 43% as recovered-not resolved, and 7% as not recovered. The mean modified Foot Function Index was 17.26, the verbal analog scale for pain score was 2.03, and implant survivorship 100% at a median of 67 (interquartile range 28.4 to 103.5) months. Although only 50% of patients reported complete symptom resolution, satisfaction was high, and most perceived themselves as recovered, suggesting recovery in hallux rigidus might not always be predicated by the complete resolution of all symptomatology. Although PROMs relying on pain inference and functional disability will continue to be utilized with increasing frequency, foot and ankle surgeons should be cognizant of their inherent limitations in assessing other forms of recovery.

Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery

BACKGROUND

Overprescription of narcotic pain medication is a major culprit in the present opioid epidemic plaguing the United States. The current literature on lower extremity opioid usage has limitations and would benefit from additional study. The purpose of our study was to prospectively assess opioid consumption patterns following outpatient orthopedic foot and ankle procedures.

METHODS

Patients undergoing outpatient orthopedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history, patient-reported outcomes, anesthesia type, procedure type, opioid prescription and consumption details. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone "pill." Univariable analyses were performed to identify variables with a statistically robust association with opioid consumption for inclusion in a multivariable linear regression. A stepwise backward regression was then performed to identify independent predictors of opioid consumption. Postoperative opioid utilization was reported for 988 patients (mean age: 49 years).

RESULTS

Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 50% and 20 631 pills left unused. Independent factors associated with higher opioid consumption were anesthesia type ( P < .004), age <60 years ( P < .001), preoperative visual analog scale (VAS) pain report of >6 ( P = .008), and bony procedures ( P = .008); residual standard error 16.73 ( F_7,844=14.3, P < .001).

CONCLUSION

Our study found that patients who underwent orthopedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although we identified 4 independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines.

LEVEL OF EVIDENCE

Level II, prospective observational cohort study.