The Importance of Patient Resilience on Outcomes Following Foot and Ankle Orthopaedic Surgery
Authors: Hewitt Michael A. , Buckley Sara E. , Hunt Kenneth 
Published: February 2023

Category: Other; Ankle Introduction/ Purpose: Recovery from orthopedic surgery requires a degree of both physical and mental resilience during recovery and rehabilitation. The brief resilience scale (BRS) is a validated and reliable 6-item screening tool that measures resilience as the ability to bounce back or recover from stress. BRS can provide unique and important information about patients coping with health-related stressors. To date, there is little evidence describing the use of BRS as a pre-operative benchmark to evaluate outcomes following foot and ankle orthopedic injuries and procedures. We aim to determine how patient resilience, as measured with BRS, may predict the impact of orthopedic conditions and recovery from foot and ankle surgery. Methods: All patients undergoing foot and ankle orthopedic surgery at a single institution were enrolled in U-COSMOS, a HIPAA-compliant, automated outcomes data repository. All patients undergoing surgery completed BRS pre-operatively. We used a BRS cutoff of < 3 (lower resilience, LR), 3-3.9 (intermediate resilience, IR), and >=4 (high resilience, HR) to create three cohorts. Patients also completed a PROMIS Physical Function (PF) Computer Adaptive Test (CAT), PROMISE Pain Interference (PI) CAT, PROMISE Depression (D) CAT, and Global Health (GH) Short Form pre-operatively as well as 3-, 6-, 12-, and 24- months post-operatively, as applicable. Patients with a minimum follow-up of 180 days were included for analysis, and the longest available follow-up was used. Differences in outcomes between the three BRS groups were determined non-parametrically using a Kruskal–Wallis one-way analysis of variance. Results: A total of 586 patients were included for analysis, with an average follow-up of 389 days. The patients were categorized as low resilience (n=44), intermediate resilience (n=229), and high resilience (n=323). Patients in the high resilience cohort had significantly higher PF and lower PI and Depression scores both pre-operatively (p < 0.05 for all) and post-operatively (p < 0.001 for all). The greatest disparity was found in depression where low resilience patients were greater than 1 SD worse than high resilience patients (Figure 1). Similar trends are observed for physical and mental global health. In addition to having higher absolute baseline and follow-up scores, the change of PF and PI is also significantly higher for high resilience patients (p = 0.02). Conclusion: Patients with high pre-operative resilience demonstrate better pre-operative physical function and pain interference scores compared to lower resilience patients and show greater improvement at 12 months post-op. We also found that lower BRS scores are associated with decreased pre- and post-operative mental health outcomes, including PROMIS Depression. Further analysis of the role of BRS in pre-operative assessment will help guide shared treatment decision-making. Identifying interventions for patients with low resilience will likely lead to improve surgical outcomes.