Abstract
Background
Patients’ characteristics, both physical and mental, are proven to have relationships to patient-reported outcomes following orthopaedic surgeries. This study aims to elucidate the impact of resilience, using the Brief Resilience Scale, on patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or Achilles tendinopathy with secondary exploratory analysis on factors influencing these outcomes.
Methods
Patients were selected utilizing the current procedural terminology code 27687 between 2013-2020. The electronic medical record was reviewed for basic demographics. Patients were contacted for patient-reported outcome measurement information system (PROMIS) scores, foot function index (FFI) scores, and brief resilience scale survey questionnaires. Pearson correlations were used to assess the association of FFI and PROMIS domains. A linear regression model was constructed to evaluate the independent effect of resilience on each FFI and PROMIS outcome instrument. A significance threshold of P < 0.05 was used to determine significance in the regression model.
Results
Increased resiliency showed a significant correlation with increased PROMIS physical function (r = 0.46, p<0.0001), decreased PROMIS pain interference (r = -0.043, p < 0.0001), and decreased PROMIS depression (r= -0.04, p < 0.0001). Increased resiliency showed a significant correlation with decreased FFI activity limitation (r= -0.047, p < 0.0001), decreased FFI disability (r = -0.53, p < 0.0001), decreased FFI pain (r = -0.36, p < 0.0001), and decreased FFI total (r= -0.52, p < 0.0001).
Conclusion
This study demonstrates the positive impact resilience has on patient-reported outcomes following isolated gastrocnemius recession for patients with a clinical diagnosis of either Achilles tendinopathy or plantar fasciitis. We were able to show a moderate correlation between higher resiliency and improved PROMIS and FFI scores for all domains. Optimizing resiliency preoperatively may help to optimize an individual's own surgical outcomes and aid physicians in managing patient expectations following surgery.
Level of Evidence: IV
Keywords: gastrocnemius, resilience, PROMIS, patient-reported outcomese
Introduction
Gastrocnemius recession (GR) is an effective treatment for equinus deformities of the foot secondary to a multitude of pathologies, most commonly gastrocnemius contracture.1-4 In a study on the prevalence of isolated gastrocnemius contractures in patients suffering from midfoot or forefoot pathology, the presence of isolated gastrocnemius contracture was 65-88%.2 Historically, GR was reserved for pediatric neurological contractures, but, as the link between isolated gastrocnemius contracture and foot pathologies has developed, the indications for performing a GR have increased both in isolation and with other procedures.3,4 With the expanded indications, the utilization of GR is becoming more frequent in the treatment of forefoot and midfoot pathologies.3-5
Patient-reported outcomes have long been used to assess the efficacy of various treatments. Commonly reported outcomes include the patient-reported outcome measurement information system (PROMIS) and the foot functional index (FFI).6-9 PROMIS was created with funding from the NIH to collect patient-reported outcomes on quality of life regarding a variety of conditions. Since its creation in 2004, many studies have found this scoring system to be a reliable tool for assessing the health burden of injuries and illnesses.10 Several studies have been conducted on the association between PROMIS scores and surgical outcomes in orthopaedics.11-13
An additional patient measurement being studied for correlations with operative outcomes is resilience. Per Smith et al., resilience is defined as the ability to bounce back or recover from a stressful event.14 This trait is considered to be stable, aiding in its ability to predict patient outcomes.15 The Brief Resilience Scale (BRS) is the current gold standard method for determining patient resilience.14,16 The BRS has shown excellent psychometric properties and has been used in multiple populations.14
There has been recent interest in using resiliency scores as a predictive model for determining patient outcomes following surgery. Past papers have studied the use of resiliency as a predictive model for outcomes following Orthopedic procedures.17-19 To our knowledge, no papers have studied the effect of resiliency on outcomes of isolated GR. The aim of this paper is to expand the knowledge of resiliency by assessing correlations between resilience and postoperative outcomes following isolated GR.
Methods
Following approval from our institution’s institutional review board (IRB), the electronic medical record was queried for the current procedural terminology code 27687 (Gastrocnemius Recession) for a single surgeon from Jan 2013 to June 2020 which yielded 479 patients. Patients were included if they underwent isolated GR and had a preoperative diagnosis of plantar fasciitis or Achilles tendinopathy. This surgeon utilized the Silfverskiold test to measure the degree of contracture of the ankle joint while isolating the gastrocnemius. A positive test for this surgeon is a loss of an estimated 8 degrees of flexion or more of dorsiflexion upon knee extension.
Patients were excluded if they had undergone concomitant surgery, had less than one year of follow-up, were under the age of 18, or declined to answer all three surveys. Patients were contacted retrospectively via phone interviews to complete outcome questionnaires. A total of 189 patients met the inclusion criteria. Utilizing the EMR, patient charts were reviewed to obtain basic patient demographic information. Clinical measures included patient American Society of Anesthesiology (ASA) scores and body mass index (BMI). Comorbidities such as tobacco and alcohol use, diabetes, hypertension, peripheral neuropathy, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), chronic kidney disease (CKD), rheumatoid arthritis (RA), and osteoporosis/osteopenia were collected. Additional variables included any history of chronic NSAID use, duration of symptoms, and a history of previous foot and ankle procedures.
Gastrocnemius Recession Surgery
This surgeon’s technique for GR is performed under general anesthesia. A posteromedial incision is made on the posterior aspect of the musculotendinous junction of the Achilles tendon. After sharp dissection through the skin and blunt dissection through the subcutaneous tissue, the paratenon is exposed with a vertical cut. Army-Navy retractors are used to keep the paratenon exposed. Complete recession of the gastrocnemius musculotendinous junction is carried out using a beaver blade. Thorough irrigation of the wound is performed. The subcutaneous tissues are closed using 4-0 Monocryl and skin closure is performed using skin staples.
Patient Reported Outcomes
The BRS, PROMIS, and Foot Function Index (FFI) scores were obtained through a combination of follow up clinic visits and phone interviews. The PROMIS pain interference (PI) version 1.1, physical function (PF) version 1.2, and depression (D) version 1.0 computer adaptive test (CATs) were collected. CATs reduce the total number of answered questions through an algorithm that selects the most relevant question based on the patient’s previous answers. Each PROMIS domain has a mean T-score of 50, representing the general population, and a standard deviation of 10. A higher score correlates with more association with the category. For example, a patient with a pain interference score of 60 has a pain score one standard deviation above that of the general population.
FFI domains of pain, disability, and activity limitation were collected and scored. Each patient's total FFI score was calculated as an average of the three domain scores. Higher scores correlate with increased pain, disability, or activity limitation.
The BRS was used to assess patient resiliency. The BRS is based on a series of six questions scored on a 5-point Likert scale. A higher score correlates with a higher level of resilience.
Statistical Analysis
Data was aggregated in Microsoft Excel and entered in R (version 4.2.0) for statistical analysis. All continuous variables were first evaluated for normality via the use of a Shapiro-Wilk test. After checking for normality, Pearson correlations were used to assess the association of variables on FFI and PROMIS domains. A linear regression model was constructed to evaluate the association of resilience with each FFI and PROMIS outcome scores, while accounting for the effects of demographic and prognostic variables (age, BMI, diabetes, history of previous operation). BRS was included in all regression models. Other variables were included in the regression models based on an a priori significance threshold of P < 0.05 in bivariate analysis.
Results
Patient demographics, comorbidities, and complications can be seen in Table 1.
Table 1.
Cohort Demographics, Procedural Characteristics, and Clinical Outcomes
| Variable | Median (range) or N (%) |
|---|---|
| Age | 49.97 (18-78) |
| Sex (F) | 138 (73.05) |
| BMI | 35.38 (18-67) |
| ASA | 2.58 (1-4) |
| Tobacco use | 54 (28.57) |
| DM | 32 (16.93) |
| PN | 31 (16.40) |
| HTN | 97 (51.32) |
| RA | 3 (1.58) |
| Equinus contracture | 131 (69.31) |
| Plantar Fasciitis | 132 (69.84) |
| Achilles Tendinopathy | 59 (31.22) |
| Chronic NSAID use | 78 (41.27) |
| Duration of Symptoms (months) | 25.67 (6-240) |
| History of Previous F/A procedures | 41 (21.69) |
| Sural Neuropathy | 20 (10.58) |
| Wound Complication | 7 (3.70) |
| Revision Surgeries | 10 (5.29) |
| Time from surgery to survey (yr) | 4.17 (1.12-9.10) |
Patient Reported Outcomes
Patient reported PROMIS, FFI and BRS scores, which were collected a median of 4.17 years postoperatively with an IQR of 3.86 (2.16 - 6.02), can be seen in Table 2.
Table 2.
Patient-Reported Outcomes Following GR
| Patient Reported Outcome | Median Scores (IQR) |
|---|---|
| PROMIS PF | 44.5 (38.6-52.7) |
| PROMIS PI | 53.9 (38.7-62.7) |
| PROMIS D | 38.9 (34.2-48.6) |
| FFI Pain | 28.00 (2-62) |
| FFI Disability | 32.22 (7.78-65.56) |
| FFI Activity Limitation | 3.00 (0-30) |
| FFI Total | 28.24 (7.65-54.12) |
| BRS | 19.00 (15.04-22.20) |
Increased resiliency, as assessed by BRS, showed a significant correlation with increased PROMIS PF (r = 0.46, p < 0.0001), decreased PROMIS PI (r= -0.043, p < 0.0001), and decreased PROMIS D (r= -0.04, p < 0.0001). Increased resiliency showed a correlation with decreased FFI activity limitation (r= -0.047, p < 0.0001), decreased FFI disability (r= -0.53, p < 0.0001), decreased FFI pain (r= -0.36, p < 0.0001), and decreased FFI total (r= -0.52, p < 0.0001).
Bivariate analysis
The results of the exploratory bivariate analysis for the factors affecting patient-reported outcomes are shown in Table 3.
Table 3.
Bivariate Analysis for the Factors Affecting Patient-Reported Outcomes
| Categorical Variable (p) | PROMIS PF (p) | PROMIS PI (p) | PROMIS D (p) | FFI Pain (p) | FFI Disability (p) | FFI Activity Limitation (p) | FFI Total (p) |
|---|---|---|---|---|---|---|---|
| BRS | <0.0001* | <0.0001* | <0.0001* | <0.0001* | <0.0001* | <0.0001* | <0.0001* |
| Previous F/A procedure | 0.12 | 0.02* | 0.02* | <0.001* | 0.01* | 0.04* | <0.0001* |
| Equinus Contracture | 0.61 | 0.54 | 0.98 | 0.48 | 0.7 | 0.94 | 0.59 |
| Plantar Fasciitis | 0.84 | 0.53 | 0.61 | 0.75 | 0.87 | 0.23 | 0.8 |
| Achilles Tendinopathy | 0.7 | 0.47 | 0.85 | 0.87 | 0.64 | 0.3 | 0.98 |
| Female Sex | 0.98 | 0.82 | 0.44 | 0.49 | 0.67 | 0.69 | 0.59 |
| Age >45 | 0.25 | 0.9 | 0.05 | 0.48 | 0.89 | 0.37 | 1 |
| BMI >30 | 0.78 | 0.23 | 0.31 | 0.09 | 0.35 | 0.48 | 0.18 |
| Tobacco Use | 0.13 | 0.04* | 0.96 | <0.0001* | <0.0001* | 0.03* | <0.0001* |
| DM | 0.62 | 0.78 | 0.02* | 0.9 | 0.83 | 0.61 | 1 |
| HTN | 0.54 | 0.09 | 0.43 | 0.05 | 0.15 | 0.18 | 0.07 |
| PN | 0.29 | 0.1 | 0.88 | 0.8 | 0.76 | 0.03* | 0.63 |
| RA | 0.46 | 0.15 | 0.01* | 0.15 | 0.74 | 0.06 | 0.96 |
| Chronic NSAID use | 0.16 | 0.22 | 0.59 | 0.49 | 0.76 | 0.81 | 0.64 |
| Symptoms longer than 2 years | 0.64 | 0.75 | 0.4 | 0.02* | 0.05 | 0.24 | 0.02* |
| Wound Complication | 0.54 | 0.46 | 0.88 | 0.43 | 0.72 | 0.09 | 0.68 |
| Revision Surgery | 0.04* | 0.06 | 0.16 | 0.04* | 0.12 | 0.06 | 0.04* |
| Follow up >3 years | 0.34 | 0.74 | 0.45 | 0.79 | 0.42 | 0.3 | 0.57 |
Figure 1 demonstrates the different beta values for BRS with bivariate analysis between the different sections of the patient-reported outcome tools used. The closer the beta value is to 1 suggests significance of these correlations. This graph does not stratify the population based on comorbidities.
Figure 1.
Beta Value of BRS with different PROM sections following GR.
Regression Analysis
Resilience was found to have statistically significant effects (p < 0.001) on all PROMIS and FFI measures when controlling for the effect of confounding variables (Table 4). However, beta values suggest a wider range of deviation for several PROMIS categories. In addition to resilience, a history of previous ankle procedure, diabetes, duration of symptoms, tobacco use, peripheral neuropathy, and wound complications were found to have statistically significant (p < 0.05) effects on PROMIS and FFI scores in multivariate analysis (Table 4).
Table 4.
Linear Regression Model for Factors Affecting Patient-Reported Outcomes
| PROMIS D | Beta p value |
|---|---|
| BRS | -0.81 0 |
| Previous F/A procedure | -4.29 0.02 |
| Age > 40 | -0.11 0.08 |
| DM | 4.04 0.05 |
| RA | 11.52 0.13 |
| PROMIS PI | Beta p value |
| BRS | -0.95 0 |
| Previous F/A procedure | -4.16 0.03 |
| Tobacco Use | 3.49 0.05 |
| PROMIS PF | Beta p value |
| BRS | 0.97 <0.0001 |
| Revision surgery | -3.84 0.25 |
| FFI pain | Beta p value |
| BRS | -2.33 0 |
| Previous F/A procedure | -18.57 0 |
| BMI > 30 | -0.34 0.21 |
| Tobacco Use | 18.7 0 |
| HTN | 5.27 0.22 |
| Symptoms more than 2 years | -0.15 0.01 |
| Revision Surgery | 18.54 0.05 |
| FFI Disability | Beta p value |
| BRS | -3.08 0 |
| Previous F/A procedure | -12.81 0.01 |
| Tobacco Use | 15.61 0 |
| Symptoms more than 2 years | -0.12 0.02 |
| FFI activity limitation | Beta p value |
| BRS | -2.38 0 |
| Previous F/A procedure | -3.46 0.45 |
| PN | 14.09 0 |
| RA | 15.5 0.39 |
| Wound complication | -14.05 0.05 |
| Revision Surgery | 9.4 0.26 |
| FFI total | Beta p value |
| BRS | -2.63 0 |
| Previous F/A procedure | -13.04 0 |
| Tobacco Use | 14.22 0 |
| HTN | 5 0.14 |
| Symptoms more than 2 years | -0.11 0.02 |
| Revision Surgery | 13.8 0.07 |
Discussion
In this study, we investigated the relationship between resilience and patient-reported outcomes following isolated GR in patients with plantar fasciitis or Achilles tendinopathy. GR is a commonly performed procedure, with a past study by Sankey et al. proving its effectiveness through improvements in PROMIS and pain VAS scores.1 Adding to prior knowledge, our results demonstrate that increased patient resilience is correlated with improvements in patient-reported outcome measures. Few papers have been published on the topic of resilience and its effect on surgical outcomes in foot and ankle surgery.20,21 To our knowledge, this is one of the largest studies on the association between resilience and its impact on post operative recovery, pain tolerance, and function following foot and ankle surgery, and the first to do so following GR.
Indications for GR include most pathologies that lead to equinus contractures such as plantar fasciitis and Achilles tendonitis.4,5,22 The purpose of the surgery is to lengthen the calf muscles and tendons at the back of the leg, relieving tightness in the calf, and subsequently decreasing pain. This procedure has a good patient satisfaction rate with one paper reporting 93% of patients saying they would recommend it to a friend.4 Previous studies have demonstrated this procedure’s ability to increase patient ankle function and decrease pain levels.4,5,22-25 The relationship between resilience and outcomes analyzed in this study can aid physicians in managing patient expectations following GR.
The interaction of biological, psychological, and social factors, termed the biopsychosocial model of disease, has typically been associated with non-surgical disease.26 More recently, however, studies have been conducted to emphasize the importance of identifying and addressing the psychosocial factors that may impact postoperative patient outcomes.26,27 Ayers et al. found that preoperative psychological factors including emotional health, social support, and coping skills correlated with functional impairment following orthopaedic surgery.27 The results of this study were in line with our own. We found that resiliency, an intrinsic psychological attribute, correlates with improvements in patient-reported outcomes. While there are limitations in how to effectively treat and/or minimize underlying psychosocial issues in a patient, they are important factors to identify and discuss when creating patient-specific guidelines for post-surgical care and framing expectations of outcomes. This paper serves to add to the growing literature on the impact of psychosocial factors on outcomes following orthopaedic procedures.
In this study, we used BRS to test for resiliency in patients who underwent GR. The BRS is the current gold standard for assessing resiliency and serves as a reliable method for measurement. Several papers have been published on using resiliency as a predictor of post-operative outcomes in orthopaedic patients.17,18,20,27-29 Similar to the findings of our study, Otlans et al., a review of the literature investigating outcomes in patients undergoing orthopaedic surgery procedures, found that various subspecialties have demonstrated positive correlations between resilience, favorable mental health, and improved physical function.20 Considering the limited amount of evidence on the relationship between mental health and post-operative outcomes following foot and ankle surgeries, we suggest that further research is required to identify other key factors influencing recovery. A thorough analysis of contributing factors enables physicians to more accurately predict patient prognosis and optimize therapies to improve physical function. This paper serves to describe the association between an intrinsic patient characteristic and surgical outcomes.
Two previous papers have described the impact of resilience on PROMIS scores following foot and ankle procedures.11,12 These previous studies both concluded that resiliency has a moderately positive impact on physical function and pain postoperatively. Our study supports and contributes to the generalization of the literature by demonstrating the positive impact resiliency plays in orthopedic outcomes. We found that increased resiliency is an independent positive factor with a moderate correlation when predicting PROMIS PF. Additionally, resiliency was found as a positive predictor for improved FFI pain, activity limitation, disability, and FFI total. While this study did find resilience to be associated with improved patient-reported outcomes, further research on the topic is warranted to expand on the mechanism of the relationship, its association with patient-reported satisfaction, and the potential development of new therapeutic and motivational techniques.
Given its retrospective design, this paper was limited in its ability to assess resilience scores in patients preoperatively. While previous literature has shown that resiliency is unchanged by surgery and other stressors, it is critical for future studies to assess BRS scores both pre- and postoperatively in the same patient.1,2,5 If a significant change in BRS scores is appreciated, this would challenge the current literature’s stance on viewing resiliency as an intrinsic patient characteristic. This study also included patients undergoing GR for a variety of pathologies. While this allows for increased generalizability of our study, we are unable to determine the effect of the different surgical indications on outcomes. Lastly, we recognize that the utilization of a phone survey to collect resiliency measures introduces potential selection and response bias.
Conclusion
This study demonstrates the positive impact of resilience on patient-reported outcomes following isolated GR in patients with Achilles tendinopathy or plantar fasciitis. While not the primary factor, resilience can be useful to physicians in estimating aspects of surgical outcomes.
References
- 1.Sanchez T, Sankey T, Schick S, et al. PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession. Foot & Ankle International. 2023;44(5):459–468. doi: 10.1177/10711007231159105. doi: [DOI] [PubMed] [Google Scholar]
- 2.DiGiovanni CW, Kuo R, Tejwani N, Price R, Hansen ST Jr, Cziernecki J, et al. Isolated gastrocnemius tightness. J Bone Joint Surg Am. 2002 Jun;84(6):962–70. doi: 10.2106/00004623-20020600000010. doi: . PMID: 12063330. [DOI] [PubMed] [Google Scholar]
- 3.Strayer LM Jr. Recession of the gastrocnemius; an operation to relieve spastic contracture of the calf muscles. J Bone Joint Surg Am. 1950 Jul;32-A(3):671–6. PMID: 15428491. [PubMed] [Google Scholar]
- 4.Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int. 2010;31(1):19–23. doi: 10.3113/FAI.2010.0019. [DOI] [PubMed] [Google Scholar]
- 5.Chimera NJ, Castro M, Manal K. Function and strength following gastrocnemius recession for isolated gastrocnemius contracture. Foot Ankle Int. 2010 May;31(5):377–84. doi: 10.3113/FAI.2010.0377. doi: . PMID: 20460063. [DOI] [PubMed] [Google Scholar]
- 6.Hung M, Baumhauer JF, Brodsky JW, et al. Orthopaedic Foot and Ankle Outcomes Research (OFAR) of the American Orthopaedic Foot and Ankle Society (AOFAS): Psychometric comparison of the PROMIS Physical Function CAT with the FAAM and FFI for measuring patient-reported outcomes. Foot Ankle Int. 2014;35(6):592–59924677217. doi: 10.1177/1071100714528492. [DOI] [PubMed] [Google Scholar]
- 7.Hung M, Baumhauer JF, Latt LD, Saltzman CL, SooHoo NF, Hunt KJ. National Orthopaedic Foot and Ankle Outcomes Research Network: Validation of PROMIS Physical Function computerized adaptive tests for orthopaedic foot and ankle outcome research. ClinOrthop Relat Res. 2013;471(11):3466347423749433. doi: 10.1007/s11999-013-3097-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hung M, Franklin JD, Hon SD, Cheng C, Conrad J, Saltzman CL. Time for a paradigm shift with computerized adaptive testing of general physical function outcomes measurements. Foot Ankle Int. 2014;35(1):1–7.24101733. doi: 10.1177/1071100713507905. [DOI] [PubMed] [Google Scholar]
- 9.Hung M, Nickisch F, Beals TC, Greene T, Clegg DO, Saltzman CL. New paradigm for patient-reported outcomes assessment in foot & ankle research: Computerized adaptive testing. Foot Ankle Int. 2012;33(8):621–626.22995227. doi: 10.3113/FAI.2012.0621. [DOI] [PubMed] [Google Scholar]
- 10.DiLiberto FE, Nawoczenski DA, Tome J, Di-Giovanni BF. Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study. Foot Ankle Surg. 2020 Oct;26(7):771–776. doi: 10.1016/j.fas.2019.10.001. doi: . Epub 2019 Oct 16. PMID: 31727534. [DOI] [PubMed] [Google Scholar]
- 11.Andrews N, Tran S, Young S, Halstrom J, Ray J, Littlefield Z, et al. Impact of Resilience on Patient Reported Outcome of First Metatarsophalangeal Arthrodesis. Osteology. 2022; May;2(2):87–98. https://doi.org/10.3390/osteology2020010 Otlans PT, Szukics PF, Bryan ST, Tjoumakaris FP, Freedman KB. Resilience in the Orthopaedic Patient. J Bone Joint Surg Am. 2021 Mar 17;103(6):549-559. doi: http://doi.org/10.2106/JBJS.20.00676. PMID: 33470590. [Google Scholar]
- 12.Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008;15(3):194–200. doi: 10.1080/10705500802222972. doi: . PMID: 18696313. [DOI] [PubMed] [Google Scholar]
- 13.Bland JS. What is the Best Way to Assess Functional Health?: The History of the Development and Application of the Patient Reported Outcome Measurement Information System (PROMIS). Integr Med (Encinitas) 2020 Feb;19(1):8–11. PMID: 32549858; PMCID: PMC7238913. [PMC free article] [PubMed] [Google Scholar]
- 14.Smith B.W, Epstein, E.M., Ortiz, J.A., Christopher, P.J., Tooley, E.M. The Foundations of Resilience: What Are the Critical Resources for Bouncing Back from Stress? In Resilience in Children, Adolescents, and Adults: Translating Research into Practice; NPrince-Embury, S., Saklofske, D.H., Eds.; New York, NY, USA: Springer; 2013. pp. 167–187. [Google Scholar]
- 15.Brodersen Freya, et al. “Impact of Preoperative Patient Education on Postoperative Recovery in Abdominal Surgery: A Systematic Review.”. World journal of surgery. 2023;47(4):937–947. doi: 10.1007/s00268-022-06884-4. doi: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008;15(3):194–200. doi: 10.1080/10705500802222972. doi: . PMID: 18696313. [DOI] [PubMed] [Google Scholar]
- 17.Haffar A, Bryan S, Harwood M, Lonner JH. “Patient Resilience Has Moderate Correlation With Functional Outcomes, but Not Satisfaction, After Primary Unilateral Total Knee Arthroplasty.”. Arthroplasty today. 20 Jul. 2021;10:123–127. doi: 10.1016/j.artd.2021.06.014. doi: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Nwankwo Vesta C, et al. “Resilience and pain catastrophizing among patients with total knee arthroplasty: a cohort study to examine psychological constructs as predictors of post-operative outcomes.”. Health and quality of life outcomes. 1 May. 2021;19(1):136. doi: 10.1186/s12955-021-01772-2. doi: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Lim KK, Matchar DB, Tan CS, et al. The association between psychological resilience and physical function among older adults with hip fracture surgery. J Am Med Dir Assoc . 2020;21:260–266.e2. doi: 10.1016/j.jamda.2019.07.005. [DOI] [PubMed] [Google Scholar]
- 20.Hoch C, Pire J, Scott DJ, Gross CE. The Influence of Pain and Resiliency on Foot and Ankle Surgery Outcomes. Foot Ankle Orthop. 2022 Jun 24;7(2):24730114221108137. doi: 10.1177/24730114221108137. doi: . PMID: 35770145; PMCID: PMC9234850. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Andrews NA, Dib A, Torrez TW, Harrelson WM, Sinha T, Rallapalle V, Agarwal A, Shah A. Impact of Patient Resilience on Outcomes of Open Brostrom-Gould Lateral Ligament Repair. J Am Acad Orthop Surg Glob Res Rev. 2021 Nov 18;5(11):e21.00103. doi: 10.5435/JAAOSGlobal-D-21-00103. doi: . PMID: 34807875; PMCID: PMC8604009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Didomenico L, Stein DY, Wargo-Dorsey M. Treatment of posterior tibial tendon dysfunction without flexor digitorum tendon transfer: a retrospective study of 34 patients. J Foot Ankle Surg. 2011 May-Jun;50(3):293–8. doi: 10.1053/j.jfas.2010.12.011. doi: . Epub 2011 Mar 11. PMID: 21397524. [DOI] [PubMed] [Google Scholar]
- 23.Kim TY, Lee HW, Jeong BO. Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty. J Foot Ankle Surg. 2020 Jan-Feb;59(1):59–63. doi: 10.1053/j.jfas.2019.07.001. doi: . PMID: 31882150. [DOI] [PubMed] [Google Scholar]
- 24.Sammarco GJ, Bagwe MR, Sammarco VJ, Magur EG. The effects of unilateral gastrocsoleus recession. Foot Ankle Int. 2006 Jul;27(7):508–11. doi: 10.1177/107110070602700705. doi: . PMID: 16842717. [DOI] [PubMed] [Google Scholar]
- 25.Sharma AK, Elbuluk AM, Gkiatas I, Kim JM, Sculco PK, Vigdorchik JM. Mental Health in Patients Undergoing Orthopaedic Surgery: Diagnosis, Management, and Outcomes. JBJS Rev. 2021 Jul 23;9(7) doi: 10.2106/JBJS.RVW.20.00169. doi: . PMID: 34297704. [DOI] [PubMed] [Google Scholar]
- 26.Magaldi RJ, Staff I, Stovall AE, Stohler SA, Lewis CG. Impact of Resilience on Outcomes of Total Knee Arthroplasty. J Arthroplasty. 2019 Nov;34(11):2620–2623.e1. doi: 10.1016/j.arth.2019.06.008. doi: . Epub 2019 Jun 12. PMID: 31278038. [DOI] [PubMed] [Google Scholar]
- 27.Ayers DC, Franklin PD, Ring DC. The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues. J Bone Joint Surg Am. 2013 Nov 6;95(21):e165. doi: 10.2106/JBJS.L.00799. doi: . PMID: 24196477; PMCID: PMC3808180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Andrews N, Dib A, Torrez T, Harrelson W, Sinha T, Rallapalle V, et al. Impact of Patient Resilience on Outcomes of Open Brostrom-Gould Lateral Ligament Repair, JAAOS: Global Research and Reviews. November 2021;Volume 5(Issue 11):e21.00103. doi: 10.5435/JAAOSGlobal-D-21-00103. doi: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Ho B, Houck JR, Flemister AS, Ketz J, Oh I, Di-Giovanni BF, Baumhauer JF. Preoperative PROMIS Scores Predict Postoperative Success in Foot and Ankle Patients. Foot Ankle Int. 2016 Sep;37(9):911–8. doi: 10.1177/1071100716665113. doi: . Epub 2016 Aug 16. PMID: 27530986. [DOI] [PubMed] [Google Scholar]