Great Expectations: Predicting Postoperative Expectation Fulfillment in Orthopaedic Foot & Ankle Patients
Authors: Henry Jensen K. , Roney Andrew R. , Hummel Amelia , Cody Elizabeth , Mancuso Carol A. , Ellis Scott J. 
Published: November 2020

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.