Do Biopsychosocial Patient Attributes Affect Our Outcomes in

Do Biopsychosocial Patient Attributes Affect Our Outcomes in

Do Biopsychosocial Patient Attributes Affect Our Outcomes in Hallux Valgus Surgery? Rachel H. Albright, DPM Midwest Podiatry Conference, 2017 Authors & Contributors Presenter Rachel Albright, DPM Co-Authors: Adam E. Fleischer, DPM, MPH, FACFAS Craig Wirt, PhD Erin Klein, DPM, MS, AACFAS Neema Patel, BS Rachel Greenley, PhD Lowell Weil Jr, DPM, MBA, FACFAS Lowell Weil Sr, DPM, FACFAS

Disclosures This work was sponsored by an ACFAS Clinical and Scientific Research Grant Award. The views expressed herein are those of the authors and do not necessarily reflect those of ACFAS Why is this Important? Hallux valgus surgery is one of the most common procedures performed by foot and ankle surgeons, but patient satisfaction is lower than what we would expect There is a paucity of research that examines what could potentially contribute to an unfavorable outcome Radiographic angles and relationships have some explanatory value, but it has been made clear that patient perception of a good outcome is multi-factorial and complex Statement of Purpose The purpose of this study is to identify whether (and to what

extent) our patients biopsychosocial attributes influence early patient reported outcomes following hallux valgus surgery Methods We prospectively studied 40 consecutive adult subjects undergoing hallux valgus surgery All subjects underwent a Scarf bunionectomy or a Scarf in combination with an Akin osteotomy, all with lateral soft tissue release Methods Primary Predictor Variable: Biopsychosocial traits were assessed using the Brief Battery for Health Improvement 2 (BBHI 2) survey, which has strong psychometric properties and covers multiple physical and psychosocial functioning domains that are known to be predictive of surgical outcome1.

1 Bruns et al . J Clin Psychol Med Settings 2009 Methods Primary Outcome Measure: Patient reported outcomes were assessed at baseline and 3 month follow up using the Foot and Ankle Outcome Score (FAOS) survey, which has been validated for use in HVS.1 This survey has five domains including symptoms, stiffness, pain, function/daily living, and function/sports and recreation 1 Chen et al. Foot Ankle Int 2012 Methods Radiographs were obtained pre and 3 months post-operatively. Eleven

biomechanical angles/measurements were assessed at both time intervals Statistical Analysis: A series of multiple regression analyses were conducted to examine associations between psychological functioning (6 BBHI 2 domains) and surgical outcomes (5 FAOS domains) P-values less than 0.05 were considered statistically significant Surgical Technique A sesamoidal release with a McGlamry elevator An osteotomy guide was used 2 headless screws were used for fixation Capsulorrhaphy was routinely performed An oblique Akin was performed when applicable

Weight bearing in a gym shoe at 1 week 6 weeks of formal physical therapy Return to full activity at 7-8 weeks postoperatively Results Variable Value Age 45.2 (sd 15.6, range 18 to 74) Female Gender 95% (38/40) Marital Status = Married

47.5% (19/40) Scarf (vs. Scarf/Akin) 55% (22/40) Bilateral (vs Unilateral) 52.5% (21/40) BBHI-2 Baseline Values Defensiveness 90.7 17.8 (Extra High) Somatic Complaints

29.9 23.3 (Average) Pain Complaints 26.3 22.4 (Low) Functional Complaints 18.7 22.9 (Low) Depression 8.4 16.1 (Extra Low) Anxiety 13.9 16.7 (Very Low)

Demographics and Baseline Characteristics (n=40). Rating provided in parentheses represents the median value for n=40 Results Change in radiographic measurements and FAOS postoperatively (n=40). Baseline FAOS FAOS - Pain FAOS - Symptoms FAOS - Activities FAOS - Sports and Recreation FAOS - QoL Radiographs 1st/2nd IM Angle (deg.) HV Angle (deg.) TSP* HA Interphalangeus Angle (deg.)

MTP Distance (mm) Mearys Angle (deg.) Hallux Equinus Angle (deg.) 3 Month F/U Change p-value 67.2 18.9 78.1 17.2 77.2 17.5 59.6 24.8 75.2 17.9 77.6 14.8 83.5 15.0

67.0 23.9 8.0 23 -0.7 3.2 6.3 18 7.4 30 <0.05 NS <0.05 <0.05 44.9 19.4 56.3 22.1 11.4 22

<0.05 11.2 3.5 22.3 9.1 4 (range 2-7) 10.4 3.6 4.9 2.4 9.6 6.7 1 (range 1-4) 12.0 4.4 6.2 3.2 12.7 7.5 2 (range 0-5) -1.7 3.5 <0.05

<0.05 <0.05 NS -2.62 3.66 8.5 6.1 10.5 5.7 -4.49 3.8 8.8 5.8 13.0 6.1 -3.18 2.11 -0.5 3.5 -2.5 5.9 <0.05 NS

NS Univariate Analysis Variables FAOS 3M Symptoms BBHI2 Defensiveness BBHI2 Functional Comp BBHI2 Anxiety TSP _C MPD_C Meary_C FAOS 3M Anxiety HAI_B HVA_3M HAI_3M MPD_C

FAOS 3M Pain 1st IM_C MPD_C FAOS 3M Sports/Recreation Meary_B Hallux Equinus_3M MPD_C FAOS 3M QOL Hallux Equinus_3M TSP_C Hallux Equinus_C Rho (r) P value -0.220 0.276

0.400 0.227 -0.302 0.294 0.172 0.085 0.011 0.164 0.061 0.069 0.301 -0.255 0.255 -0.243 0.061

0.111 0.111 0.136 -0.221 -0.313 0.175 0.052 -0.220 0.224 -0.317 0.178 0.164 0.049

0.226 0.216 -0.210 0.161 0.187 0.194 Multivariate Analysis Final Multivariate Models 8 2 4 . 2 =0 R

Final MV Model: FAOS 3M Symptoms Step Variable 1 BBHI2_Anxiety 2 MPD_Change 3 R-Sq Partial

R-Sq Model P-value 0.1568 0.157 0.01 0.0951 0.252 0.03 FAOS_Symptoms_B

0.0805 0.332 0.04 4 TSP_Change 0.0551 0.388 NS 5

Meary_Change 0.0402 0.428 NS 15% Predicting BEST Outcomes Patients who were not overly shortened (MPD change was < 4mm) were 9 times more likely to be in upper quartile (OR 9.0, p=0.048) Patients who did not have low

levels of anxiety (anxiety rating avg. or above) were 5.4 times more likely to be in upper quartile (OR 5.4, p=0.033) 3 Month FAOS Symptom Scores Anxiety Score (Baseline) vs Symptoms at 3 months r = 0.400 p = 0.010 Change in Metatarsal Length (MPD_C) vs Symptoms at 3 months r = - 0.303 p = 0.047

Conclusion As with previous studies, 1,2 we have found that radiographic variables are not particularly useful in predicting early patient reported outcomes following hallux valgus surgery. Patients who are more careful/concerned may tend to report earlier recovery after bunion surgery than those who display high levels of confidence/composure. 1 Thordarson et al. Foot Ankle Int 2005 2 Malay et al. Podiatry Institute 2011 Next Steps & Clinical Significance 1-year follow-up, larger sample size (80 enrolled) PROMIS National Institute of Healths(NIH) PROMIS (Patient Reported Outcome Measurement Information System) Need for uniform measures across Patient diverse study designs and populations Centered Outcomes assessing function and changes in that function PROMIS

Computerized adaptive testing Decreases patient burden Adaptation into EMR Superior to others HOSPITAL OF SPECIAL SURGERY FOOT & ANKLE INTERNATIONAL Higher depressive/anxiety levels were associated with higher expectations HOW CAN I USE THIS? ASSESSMENT OF PHYSICAL/PSYCHOLOGICAL SYMPTOMS, CHARACTER, ENVIRONMENT AND/

OR SOCIAL FACTORS IMPACT PATIENT RESPONSE TO NORMAL COURSE OF TREATMENT AND RECOVERY PAIN IS NOT ONE DIMENSIONAL WE ARE IDENTIFYING OBSTACLES TO PATIENT SUCCESS REFERENCES 1. Owings, M.F., and Kozak L.J. (1996) Ambulatory and inpatient procedures in the United States, 1996. National Center for Health Statistics. Vital Health Stat 13(139):27. 2. Ferrari, J., Higgins, J.P.T. and Prior, TD. (2004). Interventions for treating hallux valgus (abuctovalgus) and bunions. Cochrane Database of Systematic Reviews 2004, Issue 1. 3. Malay, D.S., Ugrinich, M. and Harris IV, W. (2011). Surrogate Markers for Patient Satisfaction after Hallux Valgus Surgery. Update Chapters: Chapter 25. Podiatry Institute. 4. Thordarson, D., Ebramzadeh, E., Moorthy, M., Lee, J., and Rudicel, S. Correlation of hallux valgus surgical outcome with AOFAS forefoot score with radiological parameters. Foot Ankle Int, 26(2):122-27, 2005. 5. Bruns, D. and Disorbio, J.M. (2009). Assessment of Biopsychosocial Risk Factors for Medical Treatment: A Collaborative Approach. J Clin Psychol Med Settings; 16:127-147. 6. Gosling S.D., Rentfrow P.J., Swann S.B. (2003). A very brief measure of the Big-Five personality domains. J Res Personality. 37:504-528.

7. Webster G.D., DeWall C.N., Pond R.S., et al. (2013). The brief aggression questionnaire: Psychometric and behavioral evidence for an efficient measure of trait aggression. Aggr Behav. 9999:1-20. 8. Weil, L.S. (2000). Scarf osteotomy for correction of hallux valgus: historical perspective, surgical technique and results. Foot Ankle Clin. 5:559-80. 9. Chen, L., Lyman, S., Do, H., Karlsson, J., Adam, S.P., Young, E., Deland, J.T. and Ellis, S.J. (2012). Validation of foot and ankle outcome score for hallux valgus. Foot Ankle Int.; Dec:33(12). 10. Duval ER, Javanbakht A, Liberzon I. Neural circuits in anxiety and stress disorders: a focused review. Ther Clin Risk Manag. 2015;11:115-26. 11. Yang H, Spence JS, Devous MD, et al. Striatal-limbic activation is associated with intensity of anticipatory anxiety. Psychiatry Res. 2012;204(2-3):12331. 12. David D, Montgomery GH, Bovbjerg DH. Relations between coping responses and optimism-pessimism in predicting anticipatory psychological distress in surgical breast cancer patients. Pers Individ Dif. 2006;40(2):203-213. 13. Kroemer NB, Guevara A, Ciocanea teodorescu I, Wuttig F, Kobiella A, Smolka MN. Balancing reward and work: anticipatory brain activation in NAcc and VTA predict effort differentially. Neuroimage. 2014;102 Pt 2:510-9. 14. Herrmann S, Ragan B, Mack M, Dompier T, Kang M. Validation of Physical Activity as a Functional Outcome Measure in Orthopedic Surgical Knee Patients: 2534.Medicine & Science in Sports & Exercise. 2008;40:S483. Thank You!! Rachel H. Albright, DPM Chicago, IL [email protected]

Next Steps & Clinical Significance 1-year follow-up Additional psychometric questionnaires - patient personality and aggression will be assessed using the Ten Item Personality Inventory (TIPI) and Brief Aggression Questionnaire (BAQ) PROMIS

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