1. Rachel H. Albright, DPM Midwest Podiatry Conference, 2017
Do Biopsychosocial Patient Attributes Affect Our Outcomes in Hallux Valgus Surgery?
Rachel H. Albright, DPM
Midwest Podiatry Conference, 2017

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.
1Bruns et al . J Clin Psychol Med Settings 2009

8. Assessment of physical symptoms, psychological, character, environment and social factors that can impact response to normal course of treatment and recovery
Pain isnt a one-dimensional experience – we are identifying obstacles that may help patients get better
Depression, somatic complaints, pain, functional, defensiveness
2 normative groups – 1st is ppl with pain, 2nd is healthy ppl (chronic pain pts have greater amounts of depression/anxiety than healthy counterparts)
If both diamonds appear in shaded area its considered normal – longer bar, the more it deviates from mean

9. 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

10. Methods 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
Radiographs were obtained pre and 3 months post-operatively. Eleven biomechanical angles/measurements were assessed at both time intervals

11. 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

12. 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 ± (Extra High)
Somatic Complaints
29.9 ± (Average)
Pain Complaints
26.3 ± (Low)
Functional Complaints
18.7 ± (Low)
Depression
8.4 ± (Extra Low)
Anxiety
13.9 ± (Very Low)
Demographics and Baseline Characteristics (n=40).
Rating provided in parentheses represents the median value for n=40

13. Results
Change in radiographic measurements and FAOS postoperatively (n=40).
Baseline
3 Month F/U
Change
p-value
FAOS
FAOS - Pain
67.2 ± 18.9
75.2 ± 17.9
8.0 ± 23
<0.05
FAOS - Symptoms
78.1 ± 17.2
77.6 ± 14.8
-0.7 ± 3.2 NS
FAOS - Activities
77.2 ± 17.5
83.5 ± 15.0
6.3 ± 18
FAOS - Sports and Recreation
59.6 ± 24.8
67.0 ± 23.9
7.4 ± 30
FAOS - QoL
44.9 ± 19.4
56.3 ± 22.1
11.4 ± 22
Radiographs
1st/2nd IM Angle (deg.)
11.2 ± 3.5
4.9 ± 2.4
6.2 ± 3.2
HV Angle (deg.)
22.3 ± 9.1
9.6 ± 6.7
12.7 ± 7.5
TSP*
4 (range 2-7)
1 (range 1-4)
2 (range 0-5)
HA Interphalangeus Angle (deg.)
10.4 ± 3.6
12.0 ± 4.4
-1.7 ± 3.5
MTP Distance (mm)
-2.62 ± 3.66
-4.49 ± 3.8
-3.18 ± 2.11
Meary’s Angle (deg.)
8.5 ± 6.1
8.8 ± 5.8
-0.5 ± 3.5
Hallux Equinus Angle (deg.)
10.5 ± 5.7
13.0 ± 6.1
-2.5 ± 5.9
TSP – median
Symptoms – 3M – swelling/bending
* Note the 1st MT became shorter – about 3 mm

14. Variables
Rho (r)
P value
FAOS 3M Symptoms
BBHI2 Defensiveness
-0.220
0.172
BBHI2 Functional Comp
0.276
0.085
BBHI2 Anxiety
0.400
0.011
TSP _C
0.227
0.164
MPD_C
-0.302
0.061
Meary_C
0.294
0.069
FAOS 3M Anxiety
HAI_B
0.301
HVA_3M
-0.255
0.111
HAI_3M
0.255
-0.243
0.136
FAOS 3M Pain
1st IM_C
-0.221
0.175
-0.313
0.052
FAOS 3M Sports/Recreation
Meary_B
0.178
Hallux Equinus_3M
0.224
-0.317
0.049
FAOS 3M QOL
0.226
0.161
TSP_C
0.216
0.187
Hallux Equinus_C
-0.210
0.194
Univariate Analysis
Postive versus negative correlations
Rho – slope – along a straight line, how much does it correlate

15. Multivariate Analysis
Final Multivariate Models
R2=0.428
Bolded is significant variables – all others that were included
5 models
Controlled for baseline scores – even with this, still is exaplined by…
The model explained half of the data in that 3M symptom – r squared

16. Final MV Model: FAOS 3M Symptoms
Step
Variable
R-Sq
Partial
R-Sq Model
P-value 1
BBHI2_Anxiety
0.1568
0.157
0.01 2
MPD_Change
0.0951
0.252
0.03 3
FAOS_Symptoms_B
0.0805
0.332
0.04 4
TSP_Change
0.0551
0.388 NS 5
Meary_Change
0.0402
0.428
15%
The variable that explained most of the variation in this model is anxiety = 15% including baseline symptoms scores

17. 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
Distribution of FAOS scores at 3M
Which ppl did the best early on aka in the upper quartile
May be able to attribute swelling to MPD change
In our population, the ppl with the lowest levels of anxiety didn’t do as well – less perceptive?

18. Anxiety Score (Baseline) vs Symptoms at 3 months
Moderate
Average anxiety score
Best fit line is a slope of .4 – anyone >.25 did not fall under 75% on FAOS

19. Change in Metatarsal Length (MPD_C) vs Symptoms at 3 months
Greater the change in length, the worse the symptom score

20. 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.
More protecting/guarding?
1 Thordarson et al. Foot Ankle Int 2005
2 Malay et al. Podiatry Institute 2011

21. Next Steps & Clinical Significance…
1-year follow-up, larger sample size (80 enrolled)
PROMIS

22. National Institute of Health’s(NIH) PROMIS
(Patient Reported Outcome Measurement Information System)
Need for uniform measures across diverse study designs and populations assessing function and changes in that function
Patient Centered Outcomes

23. PROMIS Computerized adaptive testing Decreases patient burden
Adaptation into EMR
Superior to others

24. Hospital for special surgery study – looking at expectataions

25. Hospital of Special Surgery Foot & Ankle International
Higher depressive/anxiety levels were associated with higher expectations

26. 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

27. References
1. Owings, M.F., and Kozak L.J. (1996) Ambulatory and inpatient procedures in the United States, 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:
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:
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8. Weil, L.S. (2000). Scarf osteotomy for correction of hallux valgus: historical perspective, surgical technique and results. Foot Ankle Clin. 5:
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:
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):
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):
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.

28. Thank You!!
Rachel H. Albright, DPM
Chicago, IL

29. 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