Patients’ experiences of their postoperative outcomes following forefoot surgery

Background: Hallux valgus and hallux rigidus are two common forefoot conditions causing deformity, pain, functional limitations, disability and deteriorating health status resulting in the requirement for surgery. Even when surgery is performed by an experienced surgeon there remains a potential for patients to experience dissatisfaction and unfavourable outcomes. The emotional health of the patient and behavioural consequences of pain influence the development of persistent problems and effect treatment outcomes. For example, increasing the risk of developing chronic post-surgical pain, prolonged disability, impaired quality of life and functional impairment. Disabling foot pain is likely to be multifactorial in origin, however there is a paucity of qualitative research providing insight into how patients perceive their outcomes and the factors affecting their recovery. The associated burden is therefore unknown.

Aims: The study aimed to qualitatively explore patients’ experiences of their surgical outcomes following forefoot surgery and factors associated with their recovery.

Method: This qualitative study was part of an observational study to assess whether pain catastrophizing influences post-operative outcomes following forefoot surgery. Ethical approval was granted by NRES Committee South Central and Oxford and local R&D approvals prior to data collection in a National Health Service (NHS) orthopaedic outpatients department. Semi-structured interviews with fifteen patients who received surgery for hallux valgus and/or hallux rigidus were conducted. Data were analysed using thematic analysis.

Results: Thematic analysis generated five themes; physical limitations, the psychosocial impact of surgical recovery, regaining normality, patients’ expectations for physical recovery and an altered body-image. Physical and psychosocial factors were inter-related. Patients experiencing problematic outcomes were functionally limited, had low mood and were unable to return to a normal life post-surgery. The women reported weight related issues and were limited in their footwear and clothing choices; this negatively impacted on their self-esteem.

Conclusion: A forefoot condition is multifaceted and patients need to be supported holistically. Patients experience a range of physical and psychological factors that may influence their outcomes and recovery from surgery. Poor management of persistent post-operative pain and psychosocial factors place the patient at risk of developing and maintaining chronic pain. Psychosocial factors are potentially modifiable and targeted interventions could be used in the surgical care pathway to optimise patients’ outcomes. The National Institute for Health and Care Excellence recommend the use of preoperative rehabilitation to better prepare patients physically and psychologically for surgery to optimise their outcomes and recovery. However, there remains a treatment gap in referring patients for psychological support in the surgical care pathway. To aid this, a multidisciplinary approach to care and treatment with the inclusion of allied health professionals will enable to better support patients.