Impact of Patient Diagnosis on Expectation Fulfillment in Orthopaedic Foot & Ankle Surgery
Authors: Henry Jensen K. , Roney Andrew R. , Hummel Amelia , Mancuso Carol A. , Cody Elizabeth , Ellis Scott J. 
Published: November 2020

Category: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other Introduction/Purpose: Patients’ expectations - and whether they are met - are an integral component of orthopaedic foot and ankle surgery. An expectations survey has been developed and validated to quantify patients’ expectations preoperatively and the fulfillment of those expectations postoperatively. The fulfillment of expectations correlates highly with perceived improvement, outcomes scores, and overall satisfaction with surgery, both in foot and ankle surgery and across orthopaedic subspecialties. Yet unlike other orthopaedic specialties, foot and ankle contains an inherently wide variety of patient diagnoses and procedures. This study sought to identify the effect of foot and ankle diagnosis on postoperative outcomes in terms of the extent to which expectations are fulfilled. We hypothesized that the fulfillment of expectations would vary with diagnosis. Methods: This is a prospective single-center study of adult patients undergoing elective foot and ankle surgery. Preoperatively, all patients completed the validated Expectations Survey (range 0-100, with 100 indicating maximum expectations), which asks about anticipated improvement in items like pain, ambulation, function, and more generalized items like ‘going back to normal.’ Two years postoperatively, patients noted how much improvement (none, a little, moderate, a lot, or complete) actually attained for each item cited preoperatively. This allowed for calculation of a ‘Fulfillment Proportion (FP),’ a numerical representation of whether each patient’s expectations were unmet (FP=0), partially met (FP 0-1), met as expected (FP=1), or surpassed (FP>1). FP was compared across diagnoses, and bivariate analysis between diagnoses and expectation fulfillment was performed using ordinal regression. Multivariate ordinal regression was then used to analyze the effect of diagnosis, clinical variables, and preoperative expectations on expectation fulfillment. Results: 271 of 340 (80%) patients had both preoperative and 2-year postoperative expectations data. Mean age was 55.4 years, mean BMI was 27.5 kg/m2, and 65% were female. Patients with diagnoses of midfoot/hindfoot arthritis (FP 0.68 +- .46) and neuroma (FP 0.69 +- .89) had the lowest proportion of expectations fulfilled (Table). Conversely, ankle arthritis patients had the highest proportion of expectations fulfilled (FP 0.94 +- .41). In multivariate regression analysis, diagnosis and preoperative expectations scores were significant independent predictors of low expectation fulfillment. Despite having lower preoperative expectations, neuroma patients were 5 times more likely (95% CI 1.5-14.6, p=.008) and midfoot/hindfoot arthritis patients were 3 times more likely (95% CI 1.3-8.5, p= .013) to have unfulfilled expectations. Conclusion: In orthopaedic foot and ankle surgery, the fulfillment of expectations varies with preoperative diagnosis. Patients with diagnoses of midfoot/hindfoot arthritis and neuroma were significantly more likely to have lower proportions of expectations fulfilled. Although the exact causes are unknown, possible explanations include the need for subsequent procedures, continued need for orthotics, progression of arthritis to adjacent joints in midfoot/hindfoot arthritis patients, and recurrent or residual symptoms in neuroma patients. Preoperatively, surgeons should emphasize the risks of surgery as well as the importance of realistic expectations in these patients in order to optimize their outcomes postoperatively. [Table: see text]