A qualitative study to understand patients’ experiences of their post-operative outcomes following forefoot surgery

Abstract

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. Adverse results are moderated by psychosocial variables; however, there is a paucity of qualitative research providing insight into how patients perceive their outcomes and the factors affecting their recovery.

Objective

The study aimed to qualitatively explore patients’ experiences of their surgical outcomes following forefoot surgery and factors associated with their recovery. Semi-structured interviews with 15 patients who received surgery for hallux valgus and/or hallux rigidus were conducted.

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, negatively impacting on their self-esteem.

Conclusion

A forefoot condition is multifaceted, with patients experiencing a range of physical and psychological factors that may influence their outcomes and recovery from surgery. Patients need to be supported holistically with the use of a biopsychosocial model. A multidisciplinary approach to care and treatment within the forefoot surgical pathway with the inclusion of allied health professionals will enable to better support patients to enhance their outcomes.

Introduction

Hallux valgus (HV) and hallux rigidus (HR) are two common conditions that affect the first metatarsal joint and are amongst the most prevalent forefoot conditions. Both conditions impact the joint resulting in deformity and limited movement leading to joint degeneration resulting in the requirement for surgery. ¹ In England, during 2019/20, there were over 27, 000 newly diagnosed cases of HV, HR and other deformity of hallux (acquired) and over 35, 000 operations performed. ² The prevalence is significantly higher in females and increases with advanced age.^3,4

Patients presenting for surgical consultation have significant pain, functional limitations and deteriorating health status, ¹ and post-operative expectations include improved walking agility, reduced pain and ability to wear conventional shoes with no problems.^5–7 However, even when surgery is performed meticulously by an experienced surgeon under well planned conditions, the potential remains for complications, ⁸ and some patients report dissatisfaction and unfavourable outcomes ⁹ such as persistent pain. ¹⁰ Objective measures are frequently used to examine patient-reported outcomes (PROMs) in orthopaedic surgery and increasing evidence shows that post-operative recovery and rehabilitation are influenced by patient choice and psychological traits. ¹¹ The emotional health of the patient and behavioural consequences of pain influence the development of persistent problems and effect treatment outcomes,^12,13 such as leading to the development and maintenance of chronic pain. ¹⁴ Orthopaedic surgeons now recognise the role psychological factors may play in influencing unsatisfactory outcomes. ¹⁵ However, PROMs may not allow sufficient freedom to account for different responses to the problematic issues experienced by patients and they may be more appropriately explored using open-ended questions, allowing patients to provide their own comments. ¹⁶ Yet, to date, research has yet to qualitatively investigate patients’ post-operative experiences of their surgical outcomes and the factors associated with recovery. Clinical guidelines are focused on identifying the best approach for recovery and rehabilitation to guide clinical decision making to treat patients more effectively and efficiently. To aid this process, a better understanding as to how patients perceive their post-operative outcomes and factors associated with their recovery is needed. This would offer an opportunity to develop appropriate interventions to enhance treatment outcomes and patient satisfaction.

This study aimed to qualitatively explore patients’ experiences of their post-surgical forefoot outcomes and factors associated with their recovery.

Methods

Procedure and participants

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. Patients attending an orthopaedics foot and ankle outpatient’s clinic were recruited from a secondary care setting. Patients had received a diagnosis of HV and/or HR and a surgical recommendation. Patients were recruited into the observational study and provided written informed consent to be contacted about the longitudinal additional qualitative sub-study. Those who agreed to be contacted about the sub-study were mailed a copy of the participant information sheet prior to undergoing surgery. The researcher contacted the patient by telephone to follow up their participation. For those patients willing to proceed, the researcher arranged to consent the patient into the sub-study at their convenience. This took place at the patient’s pre-assessment or a home visit was scheduled. Seventeen patients provided written informed consent prior to undergoing surgery. One individual decided not to undergo a surgical procedure and one individual was uncontactable post-surgery. In total, 15 patients were included in the analysis who participated in semi-structured interviews at three time points including three-, six- and twelve-months post-surgery. This included 14 females and one male aged between 45 and 73 years; all were White Caucasian. The male had a diagnosis of HR, three females had a diagnosis of HR, nine had a diagnosis of HV and two had a diagnosis of HR and HV. The interviews lasted between 30 min to 1 h, were audio-recorded and transcribed verbatim. All patients were assigned a pseudonym. The interviews included open-ended questions (Appendix A).

Data analysis

Data were analysed using thematic analysis ¹⁷ to allow for a flexible approach to analysis, and rich and detailed, yet complex account of data. The steps involved familiarising with the data by reading and re-reading the transcripts; generating initial codes through identifying interesting aspects of the data and establishing codes and collating them into potential themes. A sample of the data were analysed by a second independent coder, themes were discussed and agreed upon and the final themes were defined. The data analysis process involved analysing each individual interview separately, whilst documenting interesting aspects of each interview transcript. Following this, key aspects relevant to the full data set at each time point were identified. Using this approach was the most appropriate method to utilise due to the quantity of data collected. The themes generated are presented collectively across the entire data set (three-, six- and twelve-months post-surgery) as themes were commonly generated across the follow up data collection time points. Quotations that best support the themes across the participants’ experiences were selected.

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.

Physiological and physical related factors, psychosocial related factors, factors associated with regaining normality and an altered body-image as an outcome of problematic outcomes.

Theme: Physical limitations

Patients described physical related limitations as factors relating to problematic outcomes and recovery. In some patients who required revision surgery, this was due to mechanical reasons such as the removal of the implant. This caused patients ongoing pain, discomfort and/or swelling. However, some patients who experienced problematic outcomes for unknown mechanical reasons did not understand why they were continuing to experience problems. Patients experienced functional limitations as a result of ongoing problematic outcomes, this included being restricted in performing activities of daily living (ADLs) and an increase in pain whilst performing them. This affected their ability to carry out leisure activities, housework and physical exercises.

“Oh, I mean well it’s getting worse because obviously I’m trying to do more now and you know at the start you don’t expect to do very much…it’s not so bad but I mean after six months…even walking back and forward to the bus stop, and going getting shopping its ended up that I’m in agony…It’s worse, it’s worse” (Evelyn)

“But mostly I think the pain is when I’m walking and the whole idea was that getting this done would help us to walk further and…just start to get back to a little bit normality but it just…I suppose in a way I can’t complain that it’s constantly pounding or anything like that but it is still debilitating I feel like when I’m walking around it’s not great” (Charlotte)

Other functional limitations in all patients who experienced problematic outcomes included difficulties with gait. This was associated with pain, discomfort and/or swelling in the forefoot. For some patients, pain was described as being different to the pain they experienced before undergoing surgery, with pain transferred to other sites of the foot and body.

“Once the plaster came off, my foot was obviously very, very swollen which I didn’t expect…it’s been off about six, seven weeks now, and it’s still swollen and the pain and that’s when I found it the most painful, where the scar is over my bunion I’m getting sharp, sort of shooting pains across there and on the sole of my foot it’s quite tender and I can’t stop limping. I don’t know why I’m limping because I don’t need to but I can’t stop limping…It’s not because of the pain I think it’s just because it’s a little bit tender underneath and it’s swollen so it’s a bit awkward” (Hannah)

Theme: The psychosocial impact of surgical recovery

As an outcome of functional limitations, patients with problematic outcomes experienced psychosocial related problems. Being limited in activities of daily living, loss of independence and inability to take part in social events caused frustration, low mood and affected patients’ health related quality of life. They described how problematic outcomes caused them to feel anxious and/or depressed and some reported personality changes such as neurotic thought processes.

“Not being able to independently…care for myself was really big for me…that was a big thing to me, because your whole sort of persona…washing your hair, getting dressed, putting your make up on, putting your clothes on, if that’s affected, then that affects the way I feel… that has been like a big frustration to me…I find it hard to rely on people” (Jemma)

“I’m getting low now…I just feel a different person…it’s just wearing us down” (Evelyn)

Patients reported negative mood as a result of experiencing sleeping difficulties. Pain was exacerbated during the evening meaning patients were fatigued and frustrated the following day. For one patient, sleep was associated with fear of movement during sleeping and some patients recognised the role stress played in exacerbating issues with sleep and pain:

“My big toe was throbbing because the splint, and it got so bad I couldn’t sleep…I was a mess it was like somebody hammering with a nail in the end of my toe. I never slept, I never slept for days…I’m not great at the minute, I need to be getting on with things… I’m not sleeping at the minute” (Evelyn)

Whereas, in those patients who reached optimal recovery they described positive improvements on their mood, psychological wellbeing and they expressed positive personality traits such as optimism.

“I’m a bit better now…I’m not in pain so I’m a bit less sharp tempered…Oh heavens well I’m much more positive, I’m much more back to myself…enjoying life probably more than I was earlier on in the year” (Maria)

Theme: Regaining normality

For those patients getting back to a ‘normal life’ after surgery was described as positively impacting on their lives. This included being able to return to work/increase their working hours, being able to engage in more physical activity such as walking further without experiencing pain, do more exercise and take part in social events. This resulted in improved mood and overall better health related quality of life:

“Before the operation it was restricting me from doing a whole host of things as well, work and everything…whereas now, I feel I’m more almost back to normal… I can get back do doing all the things I want to do, my works not restricted I can get about…I can do all the things I want to do… I mean I’ve just come back from climbing mountains…there’s no bad feeling” (David)

“Exercising as well that all ties in doesn’t it makes you feel” (Abigail)

Whereas, patients with ongoing issues were unable to perform physical activities such as household jobs due to ongoing pain, discomfort and/or swelling. This caused some patients to be limited in the amount of walking they could perform and they were therefore unable to regain normality.

“It’s still really…sore, I can’t walk round the full of the supermarket without us being in absolute agony and I did kind of hope that was going to go…on a night time it’s all swollen on the top, it comes up like a great big lump and it aches like mad…I still can’t like walk too far or anything…at the moment…I’m wanting to do…caravan seasons starting the whole idea of getting that was getting up, getting out, getting some fresh air, doing some walking and exercise, and I genuinely don’t think right now that, that’s, going to happen…I can go to the pub but I can’t stand at the bar and talk to people, people have to come and sit down” (Charlotte)

A desire to regain normality was therefore described in terms of patients gaining positive outcomes in relation to their physical and psychosocial health. This leads to improved psychological wellbeing and enhanced patients’ quality of life.

Theme: Patients expectations for physical recovery

Patients who experienced problematic surgical outcomes emphasised how they expected to recover much quicker than they had anticipated. They did not expect to experience persistent pain and pain-related disability. Patients expectations post-surgery included reduced pain to achieve better functional outcomes such as improved gait and increased physical activity engagement.

“I think that’s one thing that they need to manage people’s expectations more…I mean I knew purely from my knee but I was told within six weeks ‘oh you’ll be walking around’… yeah that’s great but in my mind I’m going to be fit as a fiddle in six months and then I get ‘oh no it will take you at least 12 months’…I’m thinking why didn’t somebody tell me this right at the very beginning…I don’t think that they do explain enough about what your pains going to be like…how long it can go on for, or the sort of things that you will experience…I could have done with more” (Charlotte)

Some patients who were experiencing problematic outcomes were uncertain as to why they had ongoing problems and expressed the need for medical advice to help them understand why. Patients required more information on what to expect post-surgery including a need for a greater understanding as to the recovery trajectory, for example, the length of time to reach optimal outcomes and the amount of pain to be expected. Other informational needs included the appropriate time to wear the moonboot, the amount of bleeding to be experienced on the surgical dressing, the appropriate time to engage in weight bearing activities, the need of the use of walking aids, whether or not physiotherapy was required and if further surgery would be required due to the implanted screw.

It’s not knowing…I am in a position now where I don’t know what’s happening… I honestly just want my foot sorted out and I would just be totally happy with that or get a response from somebody whether it’s negative or positive” (Isabella)

“Just to have somebody to phone and say is this right? Is it to be expected to have your feet swollen? I’m a bit worried…I’m not worried in a way because when you’ve had an operation, I mean I’ve never had an operation like this before, you don’t know what to expect…If it’s something that is expected then that’s fine” (Olivia)

Patients described how an improvement in information and better management of their expectations would help to ease the associated anxiety and worry they experienced.

Theme: An altered body-image

The women reported an altered body-image as an outcome of being limited to their choice of footwear and clothing. This was due to pathological changes of the forefoot and having difficulties in finding comfortable footwear that minimised pain which, in turn, limited choice in clothing.

“I was worried…I’ve got my dress, my outfit but I knew it would be spoilt by the shoes I had to wear and that’s what’s chewed me up more than anything because I am a fashion diva…the only other thing that keeps hitting us” (Hannah)

“I mean most of the pain was in my ankle because of the way I was walking, but off course this is just the joint and the toe and its right up my foot, I can’t wear a shoe, I cannot get anything on with like hard on the top, soft trainer is all I’m managing to put on” (Evelyn)

This impacted the way the women viewed themselves and they described experiencing low self-esteem and lack of confidence. Being limited to footwear and clothing choices impacted on taking part in social events and caused anxiety:

“I feel like your identify changes a little bit and maybe that’s why I felt like I’d really aged because I couldn’t wear what I normally wore… I feel like you’re limited in what sort of clothes you can wear… if I’ve gone out on an evening it’s just because sort of more anxiety… what have I got what I can wear? How far will I have to walk to get out? You know to get to the restaurant or wherever where going, to try and get to look smartish or you know more dressing up” (Jemma)

Body-image was further impacted as a result of gaining weight due to being physically inactive and not being able to exercise. This further negatively affected women’s self-esteem and confidence and for some women they referred to avoiding social events. Whereas, positive changes to women’s body-image were experienced when they were no longer limited to their footwear choice and were able to exercise.

“I think psychologically as well and being more than middle aged woman I was starting to gain a bit of weight” (Jemma)

“I am starting to get shoes on nice shoes on, I don’t mean stilettos or anything like that, but I am starting to be able to get different shoes on compared to having to walk around in these great big clumpy shoes” (Hannah)

“I’m getting my confidence back, so I’m starting to exercise and feeling better with myself, could lose a few more pounds but I suppose everybody is in that boat” (Abigail)

Discussion

This study qualitatively explored patients’ experiences of post-operative outcomes following forefoot surgery and factors associated with recovery. Five themes were generated pertaining to physical and psychosocial factors which were inter-related and influenced by pain, factors associated with regaining normality, patients’ expectations for surgery and an altered body-image. Evidence suggests improvements can be made regarding current practice standards in the management of post-operative pain, with incidence of moderate to severe pain with orthopaedic inpatient procedures as high as 25%–50%. ¹⁸ When persistent post-operative pain is poorly managed, psychosocial factors place the patient at risk of developing and maintaining chronic pain. ¹⁴ Patients with identified mechanical causes of problematic outcomes may be treated surgically; however, there are challenges in managing post-operative pain when a cause cannot be determined. There is an unmet need in forefoot surgical patients with longer-term planning of postoperative rehabilitation required. ¹⁹

The physical related factors were inter-related with the psychosocial related factors. For example, being limited in functional performance negatively impacted on patient’s psychological wellbeing resulting in emotions such as frustration, low mood, anxiety and depression. This has been supported previously whereby, daily activity limitations and loss of enjoyment in activities because of pain, altered mood and caused negative interactions impacting on family life, leading to anxiety, bad temper, depression, embarrassment, helplessness and low self-worth. ²⁰ Patients with chronic foot and ankle pain also tend to exhibit neurotic personality traits. ²¹ This process of psychological adjustment to living with persistent pain and pain-related adjustment is typically observed in patients who are at an early stage of accepting the likely long-term nature of their pain.

Women reported an altered body-image as a result of ongoing problematic outcomes, this was impacted by being limited to their footwear and clothing choices. They reported weight gain as a result of being inactive and body-image had a psychological meaning, for example, low self-esteem and confidence issues and anxiety in social participation. This has been supported in the literature previously; being unable to return to comfortable footwear following HV surgery negatively affected women’s quality of life. ²² Whereas, positive effects on quality of life were noted when patients were able to wear conventional shows without problems. ²³ Being unrestricted in footwear and clothing are important for self-esteem. ²⁴ Whereas, negative thoughts and feelings of one’s body-image can lead to individuals feeling dissatisfied with one’s self ²⁵ and body dissatisfaction is associated with reduced quality of life and mental health and psychosocial functioning. ²⁶ Therefore, clinicians should pay careful attention to footwear concerns. ²⁷ In terms of weight concern, it may be important to educate patients about healthy eating. ²⁸

Patients undergoing an orthopaedic surgical procedure are often day cases, placing extensive responsibility to recover at home. Patients have expressed that better information about pain management would be helpful and should be delivered at multiple time points. ²⁹ Patients need knowledge and understanding concerning what constitutes the normal range in recovery and how to manage self-care following their specific procedure. ³⁰ However, overall understanding in surgical patients is poor and there is a need for greater awareness of patients’ informational needs. ³¹ Patient satisfaction with surgery and surgical outcomes are determined by their expectations and unfulfilled pre-operative expectations strongly influence dissatisfaction. Surgeons should discuss realistic expectations with patients and provide better counselling and education that is personalised to each patients’ needs. ³² Incorporating patients’ surgical expectations into clinical appointments may help improve their experiences following surgery, as well as enhance communication during the healthcare provider-patient relationship. ³³ Management of patients’ expectations through appropriate pre-operative counselling is recommended in forefoot surgery to enhance patient satisfaction. ³⁴

There is a substantial body of evidence suggesting that pain perceptions are multifaceted and can be impacted by a range of factors including psychosocial, socio-environmental and behavioural characteristics. Psychosocial factors place patients at risk of poor pain-related health and treatment outcomes including increased risk of developing chronic post-surgical pain, ³⁵ increased disability, ³⁶ reduced quality of life and functional impairment.^37,38 Patients may experience pain-related fear of movement and expectations of adverse consequences from increasing activities can contribute to disability in those with foot and/or ankle pain due to an avoidance of physical activities. ³⁶

Benefit has been suggested in treating patients prior to surgery to allow them to encode relevant information and acquire familiarity and basic proficiency with cognitive, emotion and physiological regulation skills. ³⁹ The National Institute for Health and Care Excellence (2020) recommend the use of pre-operative rehabilitation to better prepare patients physically and psychologically for surgery to optimise their outcomes and recovery. ⁴⁰ A psychologically based multidisciplinary team approach prior to surgery such as acceptance-based interventions may aid this process. Interventions that use acceptance and mindfulness techniques alongside behaviour change strategies help to increase psychological flexibility. ⁴¹ Patients are helped to develop greater psychological flexibility in the presence of thoughts, feelings and behaviours associated with pain. They are encouraged to observe thoughts and feelings as they are, without trying to change them, and behave in ways consistent with valued goals and life directions, in order to return to live as normal life as possible whilst living with persistent pain. ⁴² Our findings support the foundation of psychologically informed interventions to optimise patient’s surgical outcomes and recovery. Research is needed regarding the efficacy of interventions in the pre-operative phase of treatment. ⁴³

It is now recognised how foot and ankle surgeons’ understanding of patients’ mood and anxiety levels can contribute to improving patient care and enhancing patient-practitioner relationships, which, in turn could improve patients perceived outcomes of their surgery. ⁴⁴ Patients should be supported physically and emotionally to enhance their post-operative outcomes and recovery after surgery. The most useful approach to enhance patients’ outcomes is the biopsychosocial model as the aetiology of pain is grounded within the model and allows for identification of psychosocial factors that impact the pain experience. Psychosocial factors are potentially modifiable and therefore can be targeted in order to optimise surgical outcomes. However, a better understanding as to how to identify ‘at risk’ patients from suboptimal outcomes is needed. Some prediction models exist in orthopaedic surgeries;^45–47 however, the tools were unable or only partially able to predict patient satisfaction/dissatisfaction post-surgery and there remains a gap in foot and ankle patients. A prediction tool may benefit from the incorporation of a range of factors that have been identified in this study as associated with forefoot surgical outcomes. However, there remains a treatment gap in referring patients for psychological support in the surgical care pathway. A multidisciplinary approach to care and treatment with support from allied health professionals would help facilitate a personalised care approach to optimise patients’ surgical outcomes.

Strengths and limitations

This is the first qualitative study to subjectively explore patients’ experiences of their forefoot surgical outcomes that would have not otherwise have been routinely captured with the use of PROMs. The one male individual who was included in the sample experienced optimal outcomes from surgery, and therefore, the findings reflect women’s accounts. Nevertheless, the sample are representative of a clinical population as a higher proportion of women receive surgical consultation for HV and/or HR. Further research could seek to understand the healthcare utilisation of men, including their decision-making process to seek medical advice/surgical consultation and factors affecting their decisions.

Conclusions

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. This research has provided useful insights into the inter-related links between physical and psychosocial problems such as issues pertaining to an altered body-image. Psychosocial factors are potentially modifiable and targeted interventions could be used in the surgical care pathway to optimise patients’ outcomes. To aid this, a multidisciplinary approach to care and treatment with the inclusion of allied health professionals will enable to better support patients.

Appendix A.

S. No	Interview schedule
1	What has been your experience of your foot problem over the last few months?
2	Can you describe your experience of the surgery you received?
3	What hospital appointments have you attended, in regards to your foot?
4	What did you expect from surgery and were these expectations met?
5	What went well/did not go well?
6	How has your life changed, if it has in any way, since having surgery?
7	How would you describe the pain/discomfort that you are experiencing?
8	How is this different compared to before you received surgery?
9	Can you describe your physical functioning (e.g. how are you managing to move around)?
10	How does your foot affect you on a day-to-day basis?
11	How satisfied are you overall with your decision to have had surgery?