Preoperative Emotional Distress Negatively Impacts Foot and Ankle Outcomes
Authors: Nixon Devon , McCormick Jeremy J. , Klein Sandra , Cusworth Brian , Johnson Jeffrey 
Published: April 2018

Category: Outcomes Research Introduction/Purpose: Prior work has demonstrated that greater preoperative emotional distress leads to worse outcomes in joint arthroplasty and spine surgery. However, there is limited data on the influence of impaired preoperative psychological function on foot and ankle outcomes. Modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) can capture data on emotional distress via the PROMIS anxiety domain. PROMIS anxiety queries symptoms of fearfulness, panic, and nervousness with scores strongly correlating to multiple legacy measures of anxiety. However, PROMIS anxiety as a surrogate for emotional distress has not been utilized in orthopedic research. Here, we hypothesized that patients with greater preoperative emotional distress (i.e. higher PROMIS anxiety scores) would exhibit greater pain and less function than patients with lower anxiety following foot and ankle surgery. Methods: Elective foot and ankle surgeries from May 2016 – December 2016 were retrospectively identified. Patients with diabetes as well as those undergoing surgery for infection, trauma, or routine hardware removal were all excluded. PROMIS anxiety, pain interference (PI), physical function (PF), and depression scores were collected – data closest to surgery preoperatively and furthest from surgery postoperatively were used for analysis. Our study population was then grouped based on preoperative PROMIS anxiety, with scores greater than 60 indicating higher levels of emotional distress and scores below 60 indicating less impairment. A cutoff of PROMIS anxiety above 60 was selected as earlier studies have shown that threshold corresponds to clinically-significant amounts of anxiety based on traditional anxiety outcome measures. Additionally, PROMIS anxiety scores above 60 signify anxiety values one standard deviation or more away from the population average. Results: Patients with higher preoperative anxiety (average: 64.8, n=25) had greater preoperative pain and less function compared to patients with less preoperative anxiety (average: 47.1, n=63) (PROMIS PI: 63.6 versus 59.1, P<0.01; PROMIS PF: 37.9 versus 41.7, P<0.05; respectively). There was a strong correlation between preoperative PROMIS anxiety and depression scores (r=0.86, P<0.001). Both groups (i.e. high and low preoperative anxiety) demonstrated similar changes (P>0.1) in PROMIS PI and PF following surgery (Delta PROMIS PI: 5.1 versus 7.3; Delta PROMIS PF: 1.5 versus 3.0) at equivalent follow-up (5.7 versus 6.3 months). However, postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability compared to patients with less preoperative emotional distress (PROMIS PI: 58.5 versus 51.8, P<0.001; PROMIS PF: 39.4 versus 44.7, P<0.001). Conclusion: Evidence of preoperative emotional distress – as assessed by the PROMIS anxiety instrument – predicted worse pain and function at early surgical follow-up. Detecting patients at-risk for poorer surgical outcomes remains a topic of interest in orthopedics. Our data suggest that the PROMIS anxiety tool could be useful in identifying such patients. It would be helpful, then, to counsel individuals with higher preoperative emotional distress that – despite significant improvements – residual pain and functional disability may persist after surgery. Continued surveillance will be necessary to determine if these between-group differences remain at longer-term follow-up.