Published 4/1/2018
Maureen Leahy

Depression Associated with Low Patient Satisfaction Scores Following Hallux Valgus Surgery

Depression is often associated with poor subjective outcomes following orthopaedic surgery, yet the relationship between the mood disorder and hallux valgus surgery has not been well studied.

“Depression is prevalent in this population, and outcomes after surgical correction of hallux valgus can sometimes be suboptimal,” said Rachel Shakked, MD, of The Rothman Institute in Philadelphia. Dr. Shakked and her coauthors sought to identify whether a relationship exists between depression and patient-reported outcomes.

“We found that hallux valgus surgery patients with depressive symptoms had lower functional scores at baseline and at final follow-up than patients without depressive symptoms,” she said.

The data was presented in Scientific Poster P0207 during the AAOS 2018 Annual Meeting in New Orleans.

Retrospective review
The researchers analyzed data on 267 adult patients (88 percent female, average age = 51 years) who had undergone surgical treatment for hallux valgus over a two-year period. For each patient, they collected demographic information and the following baseline and postoperative data:

  • visual analog score (VAS)
  • Short Form-12 Physical Component Score (SF-12 PCS)
  • Short Form-12 Mental Component Score (SF-12 MCS)
  • Foot and Ankle Ability Measure (FAAM), including activities of daily living (ADL) and sports components

Patient history of depression and/or anxiety was also recorded. An SF-12 MCS ≤ 45.6 points was considered indicative of active depressive symptoms.

Baseline functional scores were available for 253 patients (95 percent). Among them, 66 patients (26 percent) reported a history of depression and/or anxiety, and 39 patients (15 percent) exhibited depressive symptoms based on MCS criteria. Baseline demographics—including age, gender, bunion severity, additional procedures performed, and length of follow-up—were similar between depressed and nondepressed patients.

All patients were contacted postoperatively by phone, at an average of 21 months, to answer a three-question satisfaction survey. Overall, 187 patients (70 percent) completed the survey. In addition, postoperative functional scores—obtained at a minimum of 11 months follow-up—were available for 162 patients (64 percent).

Depressed patients had lower satisfaction scores
Pre- and postoperative functional outcomes for both groups of patients are listed in Table 1. Statistical analysis revealed that depressed patients demonstrated greater improvement in SF-12 MCS than nondepressed patients (13.1 points vs. -2.4 points, P < 0.001). VAS improved significantly in both groups (P < 0.001), and no differences were seen in the amount of improvement in VAS between depressed and nondepressed patients.

However, depressed patients demonstrated less postoperative improvement than nondepressed patients in all other functional scores, including the following:

  • SF-12 PCS (-1.0 point vs. 2.5 points, P = 0.021)
  • total FAAM (-5.8 points vs. 4.9 points, P = 0.016)
  • FAAM ADL (-0.3 points vs. 4.5 points, P = 0.004)
  • FAAM Sport (-11.4 points vs. 2.8 points, P = 0.045)

Also, satisfaction with surgery and postoperative pain were lower in the depressed group compared to the nondepressed group (3.9 points vs. 4.5 points, P = 0.093, and 3.5 points vs. 4.4 points, P = 0.029, respectively).

“Our study found that pain levels were higher preoperatively and lower postoperatively in depressed patients. However, the depressed patients reported less satisfaction with postoperative pain than patients without depressive symptoms,” Dr. Shakked said. “Surgical correction of hallux valgus seems to effectively improve pain in depressed patients, but satisfaction with pain is inferior.”

Dr. Shakked and her coauthors believe this information may be useful during presurgical discussions with depressed patients about their prognosis.

Dr. Shakked’s coauthors of “Influence of Depression on Hallux Valgus Surgical Outcomes” are Elizabeth A. McDonald, BA; Ryan Matthew Sutton, BS; Mary-Katherine Lynch, BS; Kristen Nicholson, PhD; and Steven M. Raikin, MD.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org.