title: Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion.
abstract: BACKGROUND
  Current operative outcome scales are based on pain and function, such as the Ankle Osteoarthritis Scale (AOS). Outcomes based on patient expectation and satisfaction may be more useful. The purpose of this prospective cohort study was to evaluate associations between patient expectation, satisfaction, and outcome scores for ankle fusion and total ankle replacement (TAR).
  
  
  METHODS
  In total, 654 ankles in 622 patients were analyzed at a mean of 61 months. Patient expectation and satisfaction with symptoms were quantified pre- and postoperatively using the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaires from the American Academy of Orthopaedic Surgeons, while function was quantified using the AOS.
  
  
  RESULTS
  Patients undergoing ankle replacement had a higher preoperative expectation score (79; 95% confidence interval [CI], 77-81) compared with those undergoing ankle fusion (72; 95% CI, 68-75). Preoperative expectation scores correlated weakly with AOS scores (R (2) = 0.02) and with the "expectations met" score for ankle fusion (R (2) = 0.07) but not for ankle replacement (R (2) < 0.01). Satisfaction scores were similar for ankle fusion and ankle replacement at follow-up, but a greater number of ankle replacement patients showed improvement in satisfaction (84% vs 74%, P < .005). Higher satisfaction at final follow-up was associated with better expectations met and greater improvement in AOS outcome scores for both ankle fusion and ankle replacement. Expectations met and AOS scores at follow-up correlated for ankle fusion (R (2) = 0.38, P < .0001) and ankle replacement (R (2) = 0.31, P < .0001).
  
  
  CONCLUSIONS
  Patients undergoing TAR had higher expectation scores prior to surgery than those undergoing ankle fusion. Expectations may be more likely to be met by ankle replacement compared with ankle fusion. Ankle replacement patients were more likely to report improved satisfaction scores after surgery. Preoperative expectation scores showed little correlation with preoperative AOS scores, indicating that expectation is independent of pain and function. However, postoperative expectations met and satisfaction scores were strongly associated with AOS scores at follow-up. Better preoperative patient education may change expectations and requires study.
  
  
  METHODS
  Level II, prospective cohort study.
authors: Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada asyounger@shaw.ca.
authors: Alastair S E
authors: AS
authors: Younger
authors: Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada.
authors: Kevin J
authors: KJ
authors: Wing
authors: Department of Orthopedic Surgery, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada.
authors: Mark
authors: M
authors: Glazebrook
authors: Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors: Timothy R
authors: TR
authors: Daniels
authors: Vancouver Island Health Authority, Victoria, BC, Canada.
authors: Peter J
authors: PJ
authors: Dryden
authors: University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada.
authors: Karl-André
authors: KA
authors: Lalonde
authors: School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
authors: Hubert
authors: H
authors: Wong
authors: Centre for Health Evaluation & Outcome Sciences, University of British Columbia, Vancouver, BC, Canada.
authors: Hong
authors: H
authors: Qian
authors: Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada.
authors: Murray
authors: M
authors: Penner
mesh_terms: D000328:Adult; D000368:Aged; D000843:Ankle Joint / Q000601:surgery*; D001168:Arthritis / Q000601:surgery*; D001174:Arthrodesis / Q000379:methods*; D058737:Arthroplasty, Replacement, Ankle / Q000379:methods*; D001363:Awards and Prizes; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009985:Orthopedics; D017063:Outcome Assessment, Health Care / Q000379:methods; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012955:Societies, Medical; D011795:Surveys and Questionnaires
keywords: ankle arthritis; ankle arthrodesis; ankle fusion; expectation; operative outcomes; satisfaction; total ankle arthroplasty; total ankle replacement