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

The Relationship Between Preoperative Anxiety Level and Postoperative Pain Outcomes in Total Hip and Knee Replacement Surgery: A Cross-sectional Study

PURPOSE

Preoperative anxiety is considered a common part of the surgerical experience and can be associated with serious postoperative side effects. This study aims to determine the relationship between preoperative anxiety level and postoperative pain outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR).

DESIGN

The study used a cross-sectional and correlational research method.

METHODS

The study was conducted with a total of 104 participants, who underwent 17 THR and 87 TKR, at the Orthopedic Clinic of a state hospital in southern Turkey between June 2021 and June 2022. The State-Trait Anxiety Inventory (STAI) was used to determine preoperative anxiety level, and the Visual Analog Scale (VAS) and the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) were used to assess postoperative pain level.

FINDINGS

The mean preoperative STAI-I and STAI-II scores of the participants who underwent THR and TKR were 53.95 ± 10.51 and 44.20 ± 10.55, respectively. There was a moderate positive correlation between STAI-I scores and VAS pain scores at preoperative and postoperative 6th, 12th, 24th, and 36th hours. There was a moderate positive correlation between STAI-I scores and affective subdimension scores, a moderate positive correlation with pain severity and sleep interference and activity interference, and a weak positive correlation between STAI-II scores and pain severity and sleep interference, activity interference and affective. The factors independently affecting the 6th-hour VAS pain score were determined as male gender, THR procedure, and increasing STAI score.

CONCLUSIONS

We found that high preoperative state anxiety was associated with early postoperative pain outcomes. State anxiety was associated with pain in the 6th postoperative hour. Considering the multidimensional nature of anxiety, further research is recommended to understand the anxiety domain in surgical patients.

The Effect of Nurse-led Preoperative Visits on Anxiety: An Integrative Review

PURPOSE

This review aims to investigate the effectiveness of nurse-led preoperative visits for the reduction of presurgical anxiety. The review will explore the patterns and mechanisms through which these visits alleviate anxiety, identify the existing practice gaps, and suggest future directions for improvement. The findings will help health care providers choose appropriate visits for their patients.

DESIGN

An integrative review.

METHODS

From January 2000 to July 2023, studies on nurse-led preoperative visits were searched in Cochrane Library, Pubmed, Embase, and Web of Science databases. The search only includes English-language full-text entries. Thirteen articles were selected from the 5,741 studies discovered after the quality was rated using the Joanna Briggs Institute appraisal tool. The parameters addressed by the 13 articles chosen for evaluation included, but were not limited to, the type of research done, sample characteristics, and the types of interventions used by the researchers.

FINDINGS

Interviews between nurses and patients are the primary and most prevalent means of exchanging information during nurse-led preoperative visits. These interviews can be classified as structured, with a predetermined set of questions, and unstructured, allowing for flexibility and adaptation based on the patient's responses and needs. Audiovisual materials and written materials were provided to assist with the interview. Nurse-led preoperative visits significantly reduce feelings of anxiety by providing patient education on preoperative procedures and routines, improving trust between patients and caregivers, offering emotional support, and promoting informed decision-making through preoperative education.

CONCLUSIONS

In clinical practice, the nurse-led preoperative visit is important for lowering preoperative anxiety. The advantages of these visits may be extended to more patients by incorporating innovative methods such as improving the pattern of preoperative visits, prioritizing the nurse's role in preoperative patient visits, and using emerging technology.

Assessing the relationship between wrist synovitis and anxiety: a study using clinical statistics and Mendelian randomization analysis

BACKGROUND

Wrist synovitis often leads to persistent pain, swelling, and limited mobility, causing significant functional impairment and psychological distress, including anxiety. Although arthroscopic synovectomy can alleviate physical symptoms, whether it also improves anxiety and the causal relationship between synovitis and anxiety remains unclear.

METHODS

A prospective study was conducted on 44 patients diagnosed with wrist synovitis who underwent arthroscopic synovectomy. Patients were assessed preoperatively and at 2 and 4 weeks postoperatively using the Visual Analog Scale (VAS), Mayo Wrist Score, and Self-Rating Anxiety Scale (SAS). MR analysis was employed to investigate the causal relationship between wrist synovitis and anxiety using genome-wide association studies (GWAS) summary data.

RESULTS

Significant reductions in SAS and VAS scores were observed at 2 and 4 weeks postoperatively, along with improvements in wrist function as measured by the Mayo Wrist Score. MR analysis did not find statistically significant evidence of a direct causal relationship between wrist synovitis and anxiety, though a positive trend suggests that wrist synovitis may be a risk factor for anxiety.

CONCLUSIONS

Arthroscopic synovectomy may alleviate anxiety symptoms and may improve wrist function in patients with wrist synovitis. While a direct causal link between wrist synovitis and anxiety was not conclusively established, the observed associations highlight the need for integrated management of physical and psychological health in these patients. Trial registration This study was retrospectively registered with the WuXi 9th People's Hospital (WuXi Orthopaedics Hospital) Medical Ethical Committee on August 6, 2023, with reference number KS2023081.

Opioid use patterns following discharge from elective colorectal surgery: a prospective cohort study

INTRODUCTION

Opioid overprescription after colorectal surgery can lead to adverse events, persistent opioid use, and diversion of unused pills. This study aims to assess the extent to which opioids prescribed at discharge after elective colorectal surgery are consumed by patients.

METHODS

This prospective cohort study included adult patients (≥ 18 yo) undergoing elective colorectal surgery at two academic hospitals in Montreal, Canada. Patients completed preoperative questionnaires and data concerning demographics, surgical details, and perioperative care characteristics (including discharge prescriptions) were extracted from electronic medical records. Self-reported opioid consumption was assessed weekly up to 1-month post-discharge. The total number of opioid pills prescribed and consumed after discharge were compared using the Wilcoxon signed-rank test. Negative binomial regression was used to identify predictors of opioid consumption.

RESULTS

We analyzed 344 patients (58 ± 15 years, 47% female, 65% laparoscopic, 31% rectal resection, median hospital stay 3 days [IQR 1-5], 18% same-day discharge). Most patients received a TAP block (67%). Analgesia prescription at discharge included acetaminophen (92%), NSAIDs (38%), and opioids (92%). The quantity of opioids prescribed at discharge (median 13 pills [IQR 7-20]) was significantly higher than patient-reported consumption at one month (median 0 pills [IQR 0-7]) (p < 0.001). Overall, 51% of patients did not consume any opioids post-discharge, and 63% of the prescribed pills were not used. Increased opioid consumption was associated with younger age (IRR 0.99 [95%CI 0.98-0.99]), higher preoperative anxiety (1.02 [95%CI 1.00-1.04]), rectal resections (IRR 1.45 [95%CI 1.09-1.94]), and number of pills prescribed (1.02 [95%CI 1.01-1.03]).

CONCLUSION

A considerable number of opioid pills prescribed at discharge after elective colorectal surgery are left unused by patients. Certain patient and care characteristics were associated with increased opioid consumption. Our findings indicate that post-discharge analgesia with minimal or no opioids may be feasible and warrants further investigation.

Cardiac coherence and medical hypnosis: a feasibility study of a new combined approach for managing preoperative anxiety in patients with breast or gynaecological cancer

Background

Non-pharmaceutical approaches can help manage preoperative anxiety, but few studies have evaluated psychoeducational programmes, especially for cancer surgery. We assessed the feasibility of the COHErence Cardiaque (COHEC) programme where cardiac coherence and medical hypnosis are combined to manage preoperative anxiety in patients undergoing breast or gynaecological cancer surgical interventions (BGCSI).

Methods

Patients undergoing BGCSI were enrolled and followed a daily home programme with cardiac coherence and medical hypnosis sessions, starting 7 days before the procedure. The primary endpoint was optimal patient adherence (i.e. completion of ≥14 sessions). Secondary endpoints were anxiety levels, measured using the Visual Analogue Scale (VAS) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS), satisfaction (EVAN-G), and quality of postoperative recovery (QoR-15).

Results

In total, 53 patients [mean age: 55 (34-82) yr] were included; 83.7% had breast cancer and 15.1% had gynaecological cancer. Optimal adherence was achieved by 64.2% (95% confidence interval: 49.8-76.9%) of the intention-to-treat population. Among the 43 patients who completed at least one session, exploratory analysis showed that anxiety on the day before (P=0.02) and the morning of the intervention (P=0.04) was decreased in patients with severe anxiety at baseline (VAS ≥70). The median VAS satisfaction score for the programme was 10 (4-10). Overall, 94% of patients were willing to include the COHEC programme in their daily routine.

Conclusions

The implementation of a psychoeducational programme combining cardiac coherence and medical hypnosis is feasible and might potentially help patients undergoing BGCSI to manage preoperative anxiety. A randomised trial is underway to assess the efficacy of the COHEC programme.

Clinical trial registration

NCT03981731.

Delivery of Hand Care to Patients With High Anxiety Burden

PURPOSE

To determine whether patients presenting with Patient-Reported Outcome Measurement Information System (PROMIS) anxiety scores at >95th percentile of the US population undergo elective hand surgery at rates different from patients with less anxiety. Secondarily, we aimed to assess surgeon notation of these patients' emotional states and incidences of postoperative complications.

METHODS

This single-center retrospective cohort study analyzed data from new adult patients presenting for hand care between January 2019 and December 2020. Patients with initial PROMIS anxiety scores ≥70 were identified as the high anxiety burden (HAB) group. For each patient with HAB presenting with carpal tunnel syndrome, trigger finger, and distal radius fractures (n = 45), three controls were matched (n = 135). After matching, bivariate statistical analysis compared outcome variables of interest between patient groups. Sentiment analysis was used to explore if patient anxiety was realized and considered in surgical decision making.

RESULTS

After matching, patients with HAB averaged baseline PROMIS scores in every assessed domain that were ≥1 SD worse than unaffected patients. Patients with HAB and control patients were offered surgery at a comparable rate (58% vs 47%). Among those offered surgery, patients with HAB were less likely to undergo surgery (73% vs 92%). Postoperative complications occurred more frequently in the patients with HAB (32% vs 8%). Sentiment analysis of office notes revealed that the patients with HAB had their emotional state explicitly noted more often (40% vs 24%), but the majority of patients with HAB did not have this addressed in records.

CONCLUSIONS

Patients with HAB both underwent surgery offered less frequently and when undergoing surgery, experienced more complications. Surgeons are likely to miss opportunities to positively influence extreme patient anxiety as most patients with HAB were treated without mention of their emotional state. Future investigations should explore whether preoperative anxiety alleviation could diminish these disparities.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom Prevalence III.

Perioperative Patient Experience in Office-Based Wide-Awake Hand Surgery

PURPOSE

Office-based surgery, is a safe, well-tolerated option associated with high patient satisfaction. However, some patients remain hesitant due to concerns of being awake during surgery. Preoperative anxiety may be linked to poorer postoperative outcomes. The purpose of this study was to examine patients' distress prior to, during, and following office-based hand surgery under local anesthesia and to identify patient variables associated with distress.

METHODS

This study included 57 patients, 19 of whom had a history of anxiety and/or depression. Each patient completed the Amsterdam Preoperative Anxiety and Information Scale (APAIS) before surgery; patients completed the Subjective Units of Disturbance Scale (SUDS) before surgery, immediately after surgery, and at their first postoperative visit. They rated their SUDS with respect to the following distress domains: Being Awake During Surgery, Needlestick, Surgical Pain, and Discomfort.

RESULTS

The average distress experienced was less than the patients' preoperative expectations across all domains, and most patients rated their experiences to be equivalent to or better than expected (81 to 96% of patients, depending on the domain). Patients with elevated APAIS scores were more likely to have less distress (a better experience) than expected compared to those who were not.

CONCLUSIONS

Average distress levels experienced were better than expected. Patients with higher APAIS had less distress (better experiences) than they expected.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis II.

Factors Associated with Preoperative Anxiety in Patients Undergoing Ambulatory Hand Surgery: A Cross-Sectional Observational Study

Background: Studies examining preoperative anxiety in patients awaiting hand surgery are scarce. Preoperative anxiety is a common reaction and can have a negative impact on treatment outcomes. The aim of this study was to assess the level of anxiety in patients undergoing hand surgery as a one-day procedure and to investigate the associations between patients' preoperative anxiety and selected sociodemographic, psychological, and clinical variables. Methods: We examined 121 patients (77.7% women) who were operated on in an ambulatory setting. The mean age was 52.6 years (range: 24-84 years). Preoperative anxiety was assessed according to the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The Visual Analogue Scale was used to assess irritability, depression, and pain. Results: Univariate analyses showed significant correlations between patients' preoperative anxiety and increased age, surgery within a year since diagnosis, the presence of rehabilitation in their medical history, higher irritability, and living in rural areas. Multivariate analyses showed significant associations between patients' anxiety level and diagnosis of up to a year, a history of rehabilitation and the level of irritability. Conclusions: Patients undergoing hand surgery in an ambulatory surgery setting experience some preoperative anxiety. Younger patients, those with a shorter duration of disease, with a history of rehabilitation, those presenting intense irritability, and those living in rural areas may demand special attention.

The Influence of Resilience on Outcomes After Total Ankle Arthroplasty

BACKGROUND

Resiliency is the ability to recover from stressful events and has been shown to correlate with patient outcomes following certain orthopaedic procedures. The purpose of this study was to determine the relationship between resiliency and outcomes following TAA.

METHODS

A retrospective analysis of patients undergoing primary TAA between April 2015 and September 2022 was performed (N = 83). Data included demographics, comorbidities, complications, preoperative and postoperative visual analog scale (VAS) pain and Foot and Ankle Ability Measure (FAAM) functional scores, Brief Resilience Scale (BRS) scores, and surgical satisfaction. Patients were defined as having low resilience (LR), normal resilience (NR), or high resilience (HR) based on a BRS score of <3, 3-4.30, and >4.3, respectively.

RESULTS

High resilience patients had significantly higher postoperative FAAM ADL, Sports, and Overall scores as well as a significantly greater increase from preoperative scores compared with LR and NR patients. Low resilience patients had significantly lower FAAM Sports and Overall scores compared with normal and high resilience patients. BRS scores positively correlated with postoperative FAAM scores. We found no difference in satisfaction or VAS between the 3 cohorts. Multivariate regression analysis identified BRS scores to be an independent predictor for greater changes in FAAM scores following TAA.

CONCLUSION

Although functional improvements following TAA are expected, patients with higher resilience at baseline are more likely to experience greater improvements in functional outcomes following surgery.

LEVEL OF EVIDENCE

Level III.

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.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

Does anxiety influence outcome measurements in ankle replacement patients?

BACKGROUND

Total ankle arthroplasty (TAA) is increasingly used to treat end-stage ankle arthritis to restore ankle functional outcomes and alleviate pain. This treatment outcome may be influenced by pre-morbid patient anxiety.

METHODS

Twenty-five Infinity TAA implants were prospectively followed post-operatively with a mean follow-up time of 34.18 months. Demographic, clinical, and functional outcomes were assessed. Analysis was performed on the effect of anxiety, reported by the HADS, on patient-perceived postoperative pain, functioning, and quality of life.

RESULTS

Postoperative the PROMs and Range of Motion (ROM) improved significantly. Linear regression analysis and Pearson correlation showed a significant negative effect of anxiety on the postoperative patient-reported outcome measurements (EQ-5D-5L, VAS, and MOxFQ) at the end of follow-up.

CONCLUSION

Good functional, clinical, and radiographic results were observed in this prospective cohort study. Anxiety had a negative influence on the outcome of the patient-reported outcome measurements (EQ-5D-5L and MOxFQ) postoperatively.

LEVEL OF EVIDENCE

Level III, prospective cohort study.

The Effect of Preoperative Diagnosis of Depression and/or Anxiety on Patient-Reported Outcomes Following Chest Wall Masculinization Surgery

BACKGROUND

Individuals with gender dysphoria have disproportionately high rates of depression and anxiety compared to the cisgender population. Although the benefits of gender affirmation surgery have been well documented, it is unclear whether depression and anxiety affect postoperative patient-reported outcomes (PRO).

OBJECTIVES

The authors evaluated the impact of preoperative anxiety or depression on clinical and PRO in patients undergoing chest masculinization surgery.

METHODS

Patients who underwent chest masculinization surgery within a 5-year period were reviewed. Demographics and clinical variables were abstracted from medical records. PRO of chest, nipple, and scar satisfaction were obtained postoperatively with the BODY-Q. Groups were stratified by preoperative anxiety, preoperative depression, both, or no history of mental health diagnosis. Univariate and multivariate analyses were performed.

RESULTS

Of 135 patients with complete survey responses, 10.4% had anxiety, 11.9% depression, 20.7% both diagnoses, and 57.0% no diagnosis. Clinical data and outcomes were similar. Patients with preoperative depression correlated with lower satisfaction scores for scar appearance (P = .006) and were significantly more likely to report feelings of depression postoperatively (P = .04). There were no significant differences in chest or nipple satisfaction among groups.

CONCLUSIONS

Although anxiety and depression are prevalent in gender minorities, we found no association with postoperative clinical outcomes. Patients with preoperative depression were more likely to report lower satisfaction with scar appearance and feelings of depression postoperatively. However, there were no differences in chest or nipple satisfaction. These results highlight the importance of perioperative mental health counseling but also suggest that patients can be satisfied with their results despite a coexisting mental health diagnosis.

LEVEL OF EVIDENCE: 4

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study

BACKGROUND

Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery.

METHODS

This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors.

RESULTS

Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (β + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]).

CONCLUSION

Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

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.

Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery

Patient-Reported Outcome Measurement Information System (PROMIS) has favorable psychometric and administrative properties in orthopaedic clinical research. It facilitates clinically meaningful data collection while minimizing administration time and survey fatigue and improving compliance. PROMIS is a critical component of patient-centered care and shared decision making, as it provides enhanced communication and engagement between patients and providers. As a validated instrument, it may also aid in measuring value-based health care quality. The goal of the current work is to provide an overview of PROMIS metrics used in orthopaedic foot and ankle, including advantages and disadvantages compared to legacy scales and PROMIS's applicability in specific foot and ankle conditions based on psychometric properties. We provide a review of the literature regarding the utilization of PROMIS as an outcome measure for specific foot and ankle procedures and conditions.

Team Approach: Management of Mental Health in Orthopaedic Patients

»

Mental health evaluation should be considered an essential part of the routine preoperative assessment and should be managed by a multidisciplinary team composed of the primary care physician, orthopaedic provider, and behavioral health specialist.

»

The scientific literature indicates that patients without comorbid psychiatric symptoms and adaptive coping strategies, resilience, and well-managed expectations have improved functional outcomes and satisfaction after orthopaedic procedures.

»

Psychological issues are multifaceted and require treatment tailored to each individual patient. Therefore, close communication between all members of the care team is required to create and execute the perioperative plan.

Increasing patient-reported allergies are not associated with pain, functional outcomes, or satisfaction following medial patellofemoral ligament reconstruction: a retrospective comparative cohort study

Background

Patient-reported allergies (PRAs) are often stigmatized as a potential nonmodifiable risk factor for increased pain and worse functional outcomes following surgery. However, there is a dearth of literature directly assessing the impact of PRAs on outcomes in sport surgeries such as medial patellofemoral ligament reconstruction (MPFLR). The purpose of our study was to determine whether PRAs were associated with worse outcomes following MPFLR.

Methods

We conducted a retrospective review of patients who underwent MPFLR at our institution from 2011 to 2019. Patients were included if they had at least 12 months of follow-up. PRAs were obtained from preoperative medical assessments and categorized by drug class. Demographic and perioperative data were obtained from electronic medical records. Postoperative outcomes were measured using a telephone survey and included recurrent instability, Visual analog scale (VAS) for pain, VAS for sports, Kujala score, MPFL-Return to Sport after Injury (MPFL-RSI) score, and overall satisfaction score. Multiple linear regression was used to determine association between PRAs and outcome measures, and p-values less than 0.05 were considered significant.

Results

The cohort included 141 MPFLR. Most patients were female (98, 70%) with an average age of 25 years (range 12–56 years). Average follow-up time was 47 months. Forty-seven patients (33%) reported at least one PRA. There were no significant differences in postoperative pain, functional outcomes, satisfaction, or return to sport between patients with or without PRAs (all p > 0.05). Absence of antibiotic PRAs was predictive of higher VAS (p < 0.007), but there were no other differences. There were no significant differences in outcomes between patients without PRAs, PRAs without a concomitant psychiatric disorder, or PRAs with a concomitant psychiatric disorder (all p > 0.05).

Conclusions

In conclusion, PRAs with or without concomitant psychiatric diagnoses are not associated with worse postoperative pain, functional outcomes, or satisfaction following MPFLR with allograft, dispelling common misconceptions that increased number of allergies or psychiatric diagnoses lead to inferior surgical outcomes. Presence of antibiotic allergies was associated with lower VAS postoperative pain score. Future research should investigate the relationship between PRAs and other surgeries in the field of sports medicine.

Preoperative anxiety

PURPOSE OF REVIEW

With first research reports dating back to the 1970s, the important role of anxiety in the perioperative period has been recognized for a long time and remains in effect.

RECENT FINDINGS

The global pooled prevalence of preoperative anxiety among 14 000 surgical patients was reported to be 48%. The underlying fears among surgical patients include: fear of surgical complications, worry about the duration and degree of disability after the procedure, concerns about general anesthesia and the associated loss of control, as well as fear of waking up and experiencing discomfort and pain during or after surgery. The type and invasiveness of the planned procedure contribute to differences in preoperative anxiety levels. While preoperative anxiety is higher in younger, female patients as well as in those with a high need for information, prior exposure to anesthesia or surgery was associated with lower anxiety levels. High levels of preoperative anxiety may lead to poor postoperative pain control and increased morbidity. Due to adverse effects such as delirium, the use of benzodiazepines to manage preoperative anxiety has decreased.

SUMMARY

Preoperative anxiety remains a critical issue in the perioperative period. Further research is needed to develop effective management strategies, which may need to be tailored to the patient's individual need.

Acute postoperative pain management protocols in podiatric surgery within Australia: a Delphi study

Background

There is limited evidence in the literature to describe an analgesic protocol that takes into consideration the extent of foot and ankle surgery. The aim of this study was to develop a guide for acute postoperative pain management for podiatric surgery in Australia, and to identify opportunities to improve the current list of scheduled medicines available to podiatric surgeons.

Methods

A Delphi method involving 3 survey rounds was employed for this study. Twelve expert panellists in the field of podiatric surgery and anaesthesiology were invited to participate, and 10 panellists remained by the end of the study. Round 1 involved 15 open-ended questions. These answers formed the basis of the 55 statements that were developed for the following 2 survey rounds, where panellists rated the appropriateness of each statement on a 9-point Likert scale. The third survey round was an opportunity for panellists to revise their answers to each statement in light of the majority response.

Results

For mild acute postoperative pain, non-opioid oral analgesics were recommended as an appropriate management option. For moderate and severe acute postoperative pain, both non-opioid and opioid products were found to be appropriate by the majority. It was agreed that oral opioids be reserved for breakthrough pain at all severity levels. All other statements in the Delphi study pertaining to drug hypersensitivities or allergies, stratification of pain management, opioid prescription concerns, and access to pain medications were accepted as appropriate by the majority of panellists.

Conclusion

The agreed approach to acute postoperative pain management for podiatric surgeons in Australia was with a stepwise approach, utilising multimodal therapy, and reserving oral opioids for breakthrough pain. Additionally, there was consensus for podiatric surgeons in Australia to have wider access to alternative analgesics and anti-emetics that have similar or improved efficacies with better safety profiles.

The Influence of Pain and Resiliency on Foot and Ankle Surgery Outcomes

Background:

Resilience is the ability to recover after stressful events and has been shown to correlate with surgical outcomes. However, there has been minimal research on the impact of patient resiliency on foot and ankle surgical outcomes. This study aims to determine the predictive value of preoperative resiliency scores on surgical outcomes and investigate how this compares with the predictive value of pain scores.

Methods:

We conducted a retrospective review of adult patients who completed a preoperative Brief Resilience Scale (BRS) and underwent surgery between November 2019 and November 2020 with a fellowship-trained foot and ankle surgeon (N=184). Data included demographics, comorbidities, surgical details, complication and reoperation rates, pre- and postoperative opioid and benzodiazepine use, and additional patient-reported outcome measures (ie, visual analog scale [VAS], Pain Catastrophizing Scale [PCS], Pain Disability Index [PDI], Foot and Ankle Outcome Score [FAOS] pain subscale). Mean follow-up duration was 4.49 (range, 1.10-14.17) months.

Results:

BRS weakly correlated with decreased postoperative benzodiazepine use ( P=.007). PCS magnification ( P=.050) and helplessness ( P=.047) subscales weakly correlated with increased follow-up duration. PDI total score and most subscores significantly correlated with an increase in at least 1 of the following: follow-up duration, or postoperative opioid or benzodiazepine use. Neither the VAS nor FAOS pain subscore correlated with any outcome. PDI total score was the strongest predictor of postoperative opioid (β=0.334) and benzodiazepine (β=0.315) use. Preoperative opioid users had significantly higher PDI total score (user=39.3, nonuser=24.9; P=.012) and subscores (ie, social activity, sexual behavior, self-care, life-support activities).

Conclusion:

BRS is an unreliable tool for predicting outcomes in foot and ankle surgery, as it only weakly correlated with decreased benzodiazepine use. Rather, given the PDI’s strong associations with postoperative measures in this study, physicians should consider the value of preoperative PDI completion when predicting how foot and ankle surgery recipients will fare postoperatively.

Level of Evidence:

Level III, retrospective cohort study.

State-Anxiety in Geriatric Patients Undergoing Surgical Treatment for Femoral Neck or Intertrochanteric Fractures

Introduction

Geriatric patients with hip fractures often experience unexpected falls and they may have unfamiliar and unpleasant experiences within a brief period. This study aimed to investigate the prevalence and levels of preoperative anxiety in patients undergoing surgical treatment for hip fractures, and to determine the anxiety-related characteristics experienced by patients during the period before and after surgery.

Materials and methods

We recruited a total of 75 geriatric patients who underwent surgical treatment for hip fractures and returned complete questionnaires. We used the State-Trait Anxiety Inventory (STAI)-X type to measure state-anxiety and defined a total score of 52 or higher as clinically meaningful state-anxiety. And, we investigated main cause of anxiety, moment of the highest level of anxiety, and the most helpful factor in overcoming anxiety before surgery and in reducing anxiety after surgery.

Results

The mean STAI score was 47.2 points and one-third of the patients experienced various levels of clinically meaningful state-anxiety. The most common cause of preoperative anxiety was the surgery itself and patients experienced the greatest level of anxiety from the night preceding the surgery to the day of the surgery. Further, patients’ trust in the medical staff prior to surgery and the surgeon’s explanation after the surgery were the most key factors in overcoming anxiety.

Conclusion

This study investigates the state-anxiety of geriatric patients undergoing surgery for hip fractures and presents important findings which can help in developing evidence-based interventions to improve the experience of patients undergoing hip surgeries.

Factors affecting sufentanil consumption for intravenous controlled analgesia after hepatectomy: retrospective analysis

Background

Pain control after hepatectomy is usually achieved by opioids. There are significant individual differences in the amount of opioids used after hepatectomy, and the metabolism of opioids is liver-dependent. The purpose of our study was to explore the possible risk factors for opioid consumption during the first 48 h after surgery.

Methods

In a retrospective study design involving 562 patients undergoing open or laparoscopic hepatectomy, all patients were treated with intravenous patient-controlled analgesia (IV-PCA) along with continuous and bolus doses of sufentanil for a duration of 48 h after surgery during the time period of August 2015 and February 2019. The primary endpoint was high sufentanil consumption 48 h after hepatectomy, and patients were divided into two groups: those with or without a high PCA sufentanil dosage depending on the third quartile (Q3). The secondary endpoint was the effect of a high PCA sufentanil dosage on various possible clinical risk factors. The relevant parameters were collected, and correlation and multivariate regression analyses were performed.

Results

The median operation time was 185 min (range, 115–250 min), and the median consumption of sufentanil 48 h after the operation was 91 μg (IQR, 64.00, 133.00). Factors related to the consumption of sufentanil at 48 h after hepatectomy included age, operation time, blood loss, intraoperative infusion (red blood cells and fresh-frozen plasma), pain during movement after surgery (day 1 and day 2), preoperative albumin, and postoperative blood urea nitrogen. Age (≤ 60 and > 60 years), extent of resection (minor hepatic resection and major hepatic resection), surgical approach (laparoscope and open) and operation time (min) were independent risk factors for sufentanil consumption at 48 h postoperatively.

Conclusion

Age younger than 60 years, major hepatic resection, an open approach and a longer operation are factors more likely to cause patients to require higher doses of sufentanil after hepatectomy, and the early identification of such patients can increase the efficacy of perioperative pain management.

Effect of Spiritual Care on Anxiety and Fear of Orthopaedic Surgery Patients

Fear and anxiety can affect surgery outcomes. Spirituality is one of the basic aspects of human beings. This study determined the effect of spiritual care on the fear and anxiety of orthopaedic surgery candidates. A spiritual care programme was implemented for the experimental group. The results showed the spiritual care could reduce the anxiety and fear of orthopaedic surgery candidates. Therefore, nurses should pay more attention to spiritual care and receive the necessary training.

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.