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The Foot 17 (2007) 119–125

Factors associated with satisfaction with bunionsurgery in women: A prospective study

Jill Dawson a,b,∗, Jane Coffey b, Helen Doll a, Grahame Lavis c,Robert J. Sharp c, Paul Cooke c, Crispin Jenkinson a

a Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, United Kingdomb School of Health and Social Care, Oxford Brookes University, Marston Road Campus, Jack Straws lane,

Oxford OX3 0FL, United Kingdomc Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, United Kingdom

Received 24 June 2006; received in revised form 18 October 2006; accepted 28 November 2006

bstract

ackground: Hallux valgus is a common indication for foot surgery. Over 25% of patients are dissatisfied with the outcome.bjective: To examine women’s pre- and post-surgical characteristics, regarding satisfaction with surgery for hallux valgus (‘bunions’).ethod: Prospective cohort of 95 consecutive female patients (132 ‘foot cases’) undergoing bunion surgery. Baseline interview and ques-

ionnaire asked about attitudes to fashion and footwear, plus SF-36 general health survey. At 12 months post-surgery, patients who were ‘veryleased’ with their surgery were compared with everyone else regarding their pre-, peri- and post-operative characteristics.esults: By 12 months, key SF-36 domains had significantly improved. The 75 foot operations (n = 75/116, 64.7%) were associated with

espondents being ‘very pleased’ with their foot surgery. Following adjustment, the odds of being ‘very pleased’ were severely reduced whereespondents were not ‘very pleased’ their foot’s appearance (p < 0.001), or where foot pain was anything but absent (p = 0.018). There wasignificant interaction between pre-operative expectations of resumption of hiking/sports activities and range of footwear able to be worn

ost-operatively.onclusions: The perceived appearance of their foot and range of shoes that women can wear, are crucial to womens’ satisfaction with theutcome of bunion surgery. The (total) alleviation of pain is also important.

2006 Elsevier Ltd. All rights reserved.

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eywords: Hallux valgus; Bunion; Satisfaction; Surgery; Outcomes

. Introduction

Hallux valgus is a common condition, particularly inomen [1,2], with up to a third being affected by this condi-

ion [3,4]. Inappropriate footwear is likely to be the mainause of the condition since its prevalence is low (<4%)n unshod populations and in men [1,2,5]. Inappropriate

ootwear includes shoes that are overly tight (particularlyhose that crowd the forefoot and toes), and raised heels,hich throw the body’s weight forward and increase pres-

∗ Corresponding author at: Department of Public Health, University ofxford, Old Road Campus, Headington, Oxford OX3 7LF, United Kingdom.el.: +44 1865 289423; fax: +44 1865 289436.

E-mail address: jill.dawson@dphpc.ox.ac.uk (J. Dawson).

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958-2592/$ – see front matter © 2006 Elsevier Ltd. All rights reserved.oi:10.1016/j.foot.2006.11.003

ure on the forefoot [5]. Previous research has shown that theajority of women will not change the type of shoes theyear solely to improve a foot problem [6].Hallux valgus is one of the most common indications for

oot surgery [5]. Around 150 different surgical procedureso correct the condition have been described [7] althoughetween a quarter and a third of patients are dissatisfied withhe outcome [7,8]. It is likely that certain surgical/technicalactors are related to poor outcomes and dissatisfaction, andlinical trials of surgical interventions for hallux valgus areeeded. There are nevertheless, also likely to be other factors

hat affect outcome and satisfaction.

In the context of outcomes assessment, patients and theirlinicians may have different perceptions and perspectivesegarding the severity and relative importance of different

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20 J. Dawson et al. / Th

spects of the outcome [9,10]. Prior to surgery, they may alsoave different expectations concerning the likely outcome,uch as the restoration of a range of joint motion, or the alle-iation of pain [9,11]. Expectations, outcomes, and patientatisfaction are distinct phenomena yet are clearly related to,r mediated by, each other. Insights into the relationship thatxists between expectations, outcomes, and patient satisfac-ion are needed in the context of foot surgery. This is becausef the known high level of patient dissatisfaction with footurgery which translates into a high level of litigious activ-ty [12]. However, it is also the case that patient-centred careecognizes the obligation to understand and meet patient’sxpectations [13]. Currently there is a paucity of such infor-ation in this subject area.Based on a prospective survey of a cohort of patients

ndergoing surgery for hallux valgus, this paper examinesomen’s pre- and post-surgical characteristics, including

hose concerning fashion and footwear, in relation to theirevel of satisfaction with the outcome at 12 months post-urgery.

. Methods

Local Ethics Committee approval was obtained (Appliednd Qualitative Research Ethics Committee reference02.009) and all subjects consented to participate in the

tudy.The study recruitment period was preceded by a piloting

eriod, lasting several weeks that involved semi-structurednterviews (using prompts) with patients and piloting of ques-ionnaires. The final versions of questionnaires thus receivedonsiderable input from patients.

.1. Study population

The study sample constituted all consecutive adult patientsttending a pre-admission clinic (during an 18 month period)t an orthopaedic hospital, within 4 weeks prior to halluxalgus surgery. One hundred and eleven patients were sent aetter of invitation prior to their operation date. Of these, 100onsented to take part in the study. Power calculations hadetermined that a sample size of 100 would give 80% powero detect, at p < 0.05, a difference in proportions of 25–30%etween two groups of equal size.

Patients who agreed to participate were seen by theesearch officer during their pre-admission clinic appoint-ent. Baseline data were obtained during a 20 min interview,

sing a semi-structured interview schedule. Further detailsere obtained by self-completed questionnaire. At 12 months

ollowing surgery, patients self-completed a questionnairehile attending an out-patient clinic.

This paper reports analyses of data obtained from female

articipants only (n = 95), since the section of the interviewchedule which asked about fashion and shoes was only askedf women. Thirty-seven female participants were booked to

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17 (2007) 119–125

eceive bilateral hallux valgus surgery (total = 132 ‘cases’,.e. each foot, one case) during the same operation.

.2. Study instruments

The pre-operative interview schedule began with ques-ions about the respondent’s foot condition (using the termbunion’), including family history. Other questions includedhe importance of ‘sports which involve running; hikingr hill walking’ in the woman’s life, together with ques-ions concerned with attitudes to fashion and a section aboutootwear. The latter section employed picture cues with asso-iated questions—a method that has been used successfullyn a previous study [14]. The pictures, of currently fashion-ble styles of shoes (taken from women’s magazines), wereolour-photocopied onto an A4 size card and were dividednto three sections. Section 1 contained pictures of four back-ess sandals, all with heels <2 cm in height (shown side view,ngled from slightly above). Two of the sandals had a broadtrap which would have easily obscured the base of the hal-ux; the other two shoes had narrow straps which left the foot

uch more exposed. Section 2 contained pictures of four san-als, all with heels between 2 and 3 cm high. Again, two ofhe sandals had a broad strap covering the base of the hallux,he other two shoes left the foot much more exposed. Sectionshowed six shoes, all with heels between >3 and 7 cm high.our were backless, while two had a thin backstrap. One shoead an enclosed and very pointed/tapered toe box, while thethers were thin-strapped sandals.

All of the shoes pictured offered little support for the footnd revealed the site of the hallux valgus (or the associatedurgical scar, following surgery) to a greater or lesser extent.

Interviewees were asked a number of questions in relationo the shoe pictures, including: ‘Thinking about one year fol-owing your foot surgery, by then, would you expect to be ableo wear all of the shoes shown in these pictures?’ (responseptions: ‘yes’, ‘no’, ‘not sure’). The next question asked ifhere were any styles shown (within each of the three sectionsf pictures) that the interviewee was particularly keen to wearollowing surgery. Those who named shoes in section 3, wereoded as ‘keen to wear fashion shoes with high heels.’

Other fashion-related questions included: ‘How importants it, to you, to dress in a way that is fashionable?’ withesponse options: ‘very important’, ‘fairly important’, ‘notery important’, ‘not at all important’. The interviewee waslso asked if they had a written or implicit dress code (includ-ng shoes) for work (where applicable) and a final questionsked when the interviewee had last had their feet measured,hen buying shoes.A self-completed questionnaire followed that included

emographic items and the SF-36 general health question-aire. The SF-36 contains 36 items and is widely used as a

eneric health status instrument. It provides scores on eightimensions: physical functioning, social functioning, roleimitations due to physical problems, role limitations dueo emotional problems, mental health, energy/vitality, bod-

e Foot 17 (2007) 119–125 121

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Table 1Pre-operative items concerned with shoes and attitudes towards fashion

N (%)

Pre-operative interview (n = 91):‘Does your work involve a dress code/uniform that includes the

shoes you wear?’Yes—in writing 16 (16.8)Yes—but not in writing 18 (18.9)No 43 (45.3)Not applicable 17 (17.9)

If Yes, ‘Do you find the type of shoe that you have to wear for workcomfortable?’ (n = 33)Very comfortable 9 (27.3)Fairly comfortable 18 (54.5)Not very comfortable 4 (12.1)Very uncomfortable 2 (6.0)

‘In general, how important is it, to you, to dress in a way that isfashionable?’ (n = 94)Very important 17 (18.1)Fairly important 47 (50.0)Not very important 21 (22.3)Not at all important 9 (9.6)

‘How long ago did you last have your feet measured whenbuying shoes (years)?’Within the last year 4 (4.3)Within the last 5 years 8 (8.6)>5 but <10 years ago 6 (6.5)More than 10 years ago 72 (77.4)No idea 3 (3.2)

Items that employed shoe picture cues:Keen to wear fashion shoes with heel >3 cm high.

Yes 46 (50.5)No/not interested 45 (49.5)

Expects (post-surgery) to be able to wear any of the high fashionshoe styles shown (on cue card).

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J. Dawson et al. / Th

ly pain and general health perceptions over the last 4 weeks.cores for each dimension range from 0 (poor health) to 100good health).

The 12-month follow-up questionnaire began with theuestion: ‘How is the pain in your <right/left> foot now, com-ared with before your bunion surgery?’ (standard responseptions: ‘no pain/much better’, slightly better’, ‘no change’,slightly worse’, ‘much worse’). Further questions asked howleased the respondent was with: (i) the result of the surgery,ii) the appearance of the foot and (iii) the range of shoeshey could now wear. Response options to these three itemsere ‘very pleased’, ‘fairly pleased’, ‘not very pleased’, or

very disappointed’. The SF-36 questionnaire then followed.nformation concerning the type of surgical technique thatad been performed (e.g. Scarf, Chevron, Base osteotomy)as obtained from the participants’ operation notes, post-

urgery.

.3. Statistical methods

Data were analysed using SPSS Version 11.5 [15]. Of the5 female study recruits, 37 were booked to receive bilateralurgical procedures for hallux valgus and contributed data foroth left and right feet (n = 132 foot operation ‘cases’). Sincebservations on both feet would not be independent, analysesere conducted in two ways, depending on the topic exam-

ned. Descriptive data that related to ‘the person’ were basedn data from each woman (pre-surgery n = 95, post-surgery= 86), including for each woman listed for bilateral surgery,ut including data relating to only one of their feet (selectingor exclusion alternate right or left foot-associated data fromhe dataset). In other analyses – where information relatingo individual feet is examined – all ‘foot cases’ are includedpre-surgery n = 132, post-surgery n = 120), with statisticaldjustment made for the fact that 37 women contributed dataor both left and right feet. Denominators nevertheless vary,o a small extent, on account of missing responses on sometems.

Paired t-tests were used to examine any differences inean change scores for each of the eight dimensions of

he SF-36. Investigation of associations between individualharacteristics, both pre- and post-surgical factors, in rela-ion to satisfaction with the surgical outcome, used logisticegression. Analyses of individual variables preceded anyultiple logistic regression modeling procedures; factorsith an individual p-value <0.05 were selected for pos-

ible entry into the final model. In the multiple variableodel, post-operative factors (attitude towards the appear-

nce of the foot and foot pain) were entered in an initialtep, with pre-operative factors (including bilateral surgery)ntered subsequently using the backward stepwise method.odel fit was accessed using the Hosmer and Lemeshow

oodness-of-fit test and the classification statistic (propor-ion of observations correctly classified) was computed16]. The significance level throughout was set at two-sided< 0.05.

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Yes 25 (27.5)No/not sure 66 (72.5)

. Results

Baseline data were obtained from 95 women with aedian age of 52 years (mean 50.21, range 20–75 years).ifty women (52.6%) were booked for surgery on the rightoot, 45 (47.4%) on the left foot; these included 37 (38.9%)ooked to have both corrected. However, 9 women (9.5%)ad 12 foot operations cancelled or delayed to beyond thend of the study. Follow-up data were obtained on 116 footperations.

Table 1 details participants’ interview responses to ques-ions about footwear and fashion. These show that two-thirdsf the sample (n = 64, 68%) considered it to be fairly or verymportant to dress fashionably and around half of those inter-iewed (n = 46, 50.5%) indicated that they were keen to wearashionable shoes with elevated heels (>3 cm) following footurgery.

Table 2 presents mean pre-operative, 12 months post-perative and change (pre-operative minus post-operative)cores for the SF-36 general health status domains (scoring00 denotes best possible health status). These show that

122 J. Dawson et al. / The Foot 17 (2007) 119–125

Table 2Mean pre-operative, 12 month post-operative and change scores for SF-36 domains in women undergoing surgery for hallux valgus, plus UK general populationnormative values [22]

Pre-surgery,mean (S.D.)

Post-surgery,mean (S.D.)

Change, mean (95% CIs) t-Test General population [22]

t p N = 9332 mean (S.D.)

SF-36 domains:Physical function, N = 72 75.14 (22.22) 84.72 (19.04) −9.58 (−13.93 to −5.24) −4.40 <0.001 88.40 (17.98)

Pain, N = 80 62.36 (24.97) 75.97 (22.67) −13.61 (−19.69 to −7.53) −4.46 <0.001 81.49 (21.69)Role physical, N = 80 78.05 (26.59) 84.61 (25.60) −6.56 (−13.27 to 0.15) −1.95 0.055 85.82 (29.93)Role mental, N = 81 83.25 (23.70) 89.81 (19.28) −6.58 (−12.48 to −0.69) −2.22 0.029 82.93 (31.76)Mental health, N = 82 70.73 (17.30) 76.89 (17.21) −6.16 (−9.59 to −2.73) −3.57 0.001 73.77 (17.24)Energy, N = 80 57.02 (20.24) 62.27 (17.83) −5.25 (−9.28 to −1.21) −2.59 0.012 61.13 (19.67)

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Social function, N = 79 78.80 (23.63) 84.65 (21.65)Health perception, N = 76 76.59 (18.94) 78.49 (17.37)

re-operative pain, energy/vitality and mental health scoresere particularly reduced compared with general popula-

ion norms. By 12 months following surgery, key domainsad improved considerably and most domain scores hadignificantly improved. There were no significant differ-nces between women undergoing unilateral versus bilateralurgery on any of the SF-36 domains.

The next series of analyses included 12-month follow-upata from patient questionnaires taking the foot that receivedurgery as the unit of analysis (n = 116). At 1 year followingurgery, 75 foot operations (n = 75/116, 64.7%) were associ-ted with the respondent being ‘very pleased’ with the resultf their foot surgery, with 30 (25.9%) operations associatedith the response ‘fairly pleased’, 6 (5.2%) ‘not very pleased’

nd 5 (4.3%) ‘very disappointed’.Table 3 presents results from unadjusted logistic regres-

ion analyses of odds ratios (with 95% confidence intervals,Is) for demographic, operative, pre- and post-operativeharacteristics associated with respondents stating that theyere ‘very pleased’ with the outcome of their bunion surgery

concerning the particular foot operated on) in comparisonith giving any other (less pleased) response.Variables that had a significant association with being

very pleased’ with the surgical outcome, in unadjusted analy-es, were examined further using multiple logistic regression.ariables were added using backward stepwise selection tobaseline model containing post-operative variables con-

erned with foot pain and the perceived appearance of theoot. The range of shoes that the women said they couldear post-surgery was not entered in the model as it wasighly associated with both foot pain and satisfaction withhe appearance of the foot. The results of the final model arehown in Table 4. This was the most stable model, whichccounted for between 35 and 48 percent of the variance, andith satisfactory model fit.Following adjustment, the odds of being ‘very pleased’

ith the outcome of bunion surgery were reduced by nearly

5% for operations where the respondent was not ‘veryleased’ with the appearance of their foot following surgeryOR 0.06, 95% CIs 0.02–0.19, p < 0.001). The alleviation ofain was also important, with the odds of being ‘very pleased’

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(−11.66 to 0.05) −2.01 0.048 88.01 (19.58)(−5.48 to 1.69) −1.07 0.289 73.52 (19.90)

ith the outcome substantially reduced where foot painas anything but absent. The odds of being ‘very pleased’ith the outcome reduced by over 90% where the respon-ent had expressed expectations (prior to surgery) that theyould resume ‘some’ – rather than ‘all’ (reference category,R = 1.00) – running, hiking or hill-walking activities by2 months following surgery (OR 0.09, 95% CIs 0.02–0.45,= 0.003).

Further exploration showed that this particular expec-ation had been expressed by just eight women, none ofhom were ‘very pleased’ with the surgical outcome. This

s likely to reflect the fact that none of these women wereery pleased with the range of footwear they were able toear, half being only ‘fairly pleased’ and half ‘not pleased orery disappointed’. There was thus a significant interactionetween pre-operative expectation of resumption of activitiesnd range of footwear able to be worn post-operatively, withhe observed relationship between expected resumption ofnly some activities and dissatisfaction with outcome at leastartly reflecting this interaction. After adjusting for the inter-ction between range of shoes and expectation of resumptionf activities, there was no significant association betweenhese expectations and satisfaction.

. Discussion

Based on a sample of consecutive female patients about tondergo surgery, this study has examined patient character-stics, attitudes and stated expectations that might reasonablye expected to have a bearing on their level of satisfactionith surgery to correct hallux valgus.Averaging around 50 years of age, the women in our study

evertheless represented a wide age-range, of whom aroundalf had had their hallux valgus condition for at least 25 years.nitial investigation of issues related to fashion and footwearevealed that over three-quarters of the sample (77.4%) had

ot had their feet measured in over 10 years when buyinghoes, despite having a foot deformity. This compares with6% of female general orthopaedic out-patients surveyed inn American study, who had last had their feet measured at

J. Dawson et al. / The Foot 17 (2007) 119–125 123

Table 3Odds ratios (plus 95% confidence intervals (CI)) for pre- and post-operative characteristics associated with being ‘very pleased’ with the outcome of surgeryfor hallux valgus in women

(R) reference category All Very pleased withsurgery No. %

All otherresponses No. %

Oddsratio

95% CI p-Value

Demographic and operative characteristicsAge group (years) (n = 116)

<40 [R] 27 (23.3) 14 (51.9) 13 (48.1) 1.0040–60 60 (51.7) 38 (63.3) 22 (36.7) 1.60 0.64–4.02 0.31>60 29 (25.0) 23 (79.3) 6 (20.7) 3.56 1.10–11.51 0.03

Bilateral—both feet received surgery at the same time (n = 113)Yes [R] 67 (57.8) 42 (62.7) 25 (37.3) 1.00No 49 (42.2) 33 (67.3) 16 (32.7) 1.16 0.54–2.53 0.70

Operative technique (n = 115)Scarf [R] 99 (86.1) 64 (64.6) 35 (35.4) 1.00Other 16 (13.9) 10 (62.5) 6 (37.5) 0.91 0.31–2.72 0.87

Pre-operative interviewBelieves it is important to dress fashionably: (n = 115)

Very important [R] 22 (19.1) 16 (72.7) 6 (27.3) 1.00Fairly important 56 (48.7) 33 (58.9) 23 (41.1) 0.54 0.18–1.58 0.26Not very/at all important 37 (32.2) 25 (67.6) 12 (32.4) 0.78 0.24–2.50 0.68

Keen to wear fashion shoes with heel >3 cm high: (n = 112)Yes [R] 58 (51.8) 39 (67.2) 19 (32.8) 1.00No/not interested 54 (48.2) 33 (61.1) 21 (38.9) 0.77 0.35–1.66 0.50

Sports/activities that involve running, hiking or hill walking are an important part of my life: (n = 115)Yes, very important [R] 60 (52.2) 35 (58.3) 25 (41.7) 1.00Fairly important 27 (23.5) 20 (74.1) 7 (25.9) 2.04 0.75–5.56 0.16Not very/at all important 28 (24.3) 19 (67.9) 9 (32.1) 1.51 0.59–3.88 0.39

Expects to be able to wear any of the high fashion shoe styles shown (on cue card), post-surgery: (n = 112)Yes 33 (29.5) 23 (69.7) 10 (30.3) 1.00No/not sure 79 (70.5) 49 (62.0) 30 (38.0) 0.71 0.30–1.70 0.44

Expects to resume running, hiking or hill walking, post-surgery: (n = 113)Yes—all 47 (41.6) 31 (66.0) 16 (34.0) 1.00Yes—some 17 (15.0) 4 (23.5) 13 (76.5) 0.16 0.04–0.57 0.005No/not interested 49 (43.4) 37 (75.5) 12 (24.5) 1.59 0.66–3.87 0.31

Post operative (1 year) factors:Attitude towards appearance of foot (n = 116)

Very pleased [R] 73 (62.9) 62 (84.9) 11 (15.1) 1.00Less than very pleased 43 (37.1) 13 (30.2) 30 (69.8) 0.08 0.03–0.19 <0.001

Attitude towards range of shoes can now wear (n = 113)Very pleased [R] 38 (33.6) 37 (97.4) 1 (2.6) 1.00Fairly pleased 44 (38.9) 22 (50.0) 22 (50.0) 0.03 0.00–0.22 0.001Not very pleased/disappointed 31 (27.4) 13 (41.9) 18 (58.1) 0.02 0.00–0.16 <0.001

Foot pain (n = 116)No pain at all [R] 41 (35.3) 36 (87.8) 5 (12.2) 1.00Much better 49 (42.2) 30 (61.2) 19 (38.8) 0.22 0.07–0.66 0.007Slightly better 11 (9.5) 1 (9.1) 10 (90.1) 0.01 0.00–0.13 <0.001

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No change/worse 15 (12.9) 8 (53.3)

nadjusted analysis (logistic regression). N = 116 cases (foot operations).

east 10 years previously [2]. Because feet generally changen size and shape from one decade to the next and if shoes areot adjusted accordingly, the risk of developing foot deformi-ies (including hallux valgus), or perhaps re-developing them

ost-surgery, is increased [5].

Prior to surgery, wearing fashionable attire was consideredmportant by over two-thirds of the sample, while over a quar-er of the sample said that, by 1 year following surgery, they

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xpected to be able to wear any of the examples of currentlyashionable shoes shown on a cue-card. These examplesncluded shoes with high heels or with very pointed toe-ox, and sandals with thin straps which would fully expose

heir feet. Those who expressed such expectations might beonsidered to be women with high (perhaps, in some cases,nrealistic) expectations of their surgical outcome. Generallypeaking, pre-operative expectations about the desired out-

124 J. Dawson et al. / The Foot 17 (2007) 119–125

Table 4Odds ratios for (and 95% CIs) pre- and post-operative factors associated with being ‘very pleased’ with the outcome of surgery for hallux valgus in women

(R) reference category n = 113 (foot operations) Adjusted odds ratio 95% CI χ2 p-Value

Post operative (1 year) factorsa

Attitude towards appearance of footVery pleased [R] 1.00 23.27 <0.001Less than very pleased 0.06 0.02–0.19 <0.001

Foot pain 8.03 0.018No pain at all [R] 1.00Much better 0.24 0.06–0.91 0.036Slightly better/No change/worse 0.11 0.03–0.52 0.005

Pre-operative factors:b

Expects to resume running, hiking or hill walking, post-surgery: (n = 113) 10.97 0.004Yes—all 1.00Yes—some 0.09 0.02–0.45 0.003No/not interested 1.36 0.42–4.39 0.61

Adjusted model (multiple logistic regression). Estimate of variance accounted for in the analysis: Cox and Snell R Square = 0.35. Nagelkerke R Square = 0.48.G

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oodness of fit statistic: Hosmer & Lemeshow test χ2 0.40 d.f. 4 p = 0.98.a Simultaneous entry.b Backward stepwise selection.

ome of an intervention will, in turn, modify the degree ofatisfaction that a patient expresses with the outcome of theirurgery [17,18].

Our analysis of SF-36 general health status domainsevealed pre-operative scores that were generally very similaro those obtained for people aged 35–44 years in an Americantudy of female patients undergoing surgical correction forallux valgus [19], although scores for pain and role physicalomains appeared less severe (by between 7 and 10%) in ourtudy. These domains were nevertheless reduced by between0 and 20% by comparison with previously published UKeneral population scores. This contributes to the body of evi-ence that hallux valgus is a debilitating and painful conditionor many; while others have also found that the condition con-ributes to instability and risk of falling in older people [20].

By 12 months following surgery, SF-36 physical functionnd pain domains had improved the most, although these weretill ∼5% lower than general population norms. All otheromains had improved – the majority significantly so – gen-rally to levels higher than those for the general population.

Almost two-thirds (64.7%) of the foot operations weressociated with the patient being ‘very pleased’ with the sur-ical outcome at 12 months post-surgery. Exploration of theelationship between respondents’ demographic, operative,re- and post-operative characteristics in relation to oper-tions with which they were ‘very pleased’ (at 12 monthsollowing surgery) revealed three important factors, each ofhich considerably reduced the odds of women reporting that

hey were ‘very pleased’ with the outcome. These includedaving foot pain that, 1 year following surgery, was onlylightly better – or worse – than before surgery. The nextmportant factor concerned a pre-operative expectation, that

ome (rather than all) of running, hiking or hill-walking activ-ties would be resumed following surgery. While this findingppeared curious, closer examination suggested that the sameomen who had expressed this expectation had all been less

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han ‘very pleased’ with the range of shoes they were able toear post-surgery.The need to correct footwear problems, the alleviation of

ain and restoration of adequate walking function have allreviously been highlighted as the most important influencesn the outcome of surgery for hallux valgus [9], however,e found that the most important factor associated withomen being less than ‘very pleased’ with the outcome of

heir surgery related to the appearance of their foot (thisariable was also closely associated with the range of shoeshat they were able to wear); as those who were not ‘veryleased’ with the appearance of their foot were very unlikelyo be very pleased with the overall outcome of their surgery.othing stated at the pre-operative stage presaged who thoseomen would be.The main limitation of this observational study is that

hile consecutive surgical cases were recruited over a sus-ained period, our sample nevertheless only represented oneurgical centre. Therefore, it is possible that our findings mayack generalisability. Nevertheless, strength of the study ishat its design was longitudinal. Furthermore, with studieseporting between a quarter and a third of patients to be dis-atisfied with the outcome of bunion surgery [8], and in viewf the fact that foot problems impair many aspects of health-elated quality of life [21], clearly further insights into theatient’s perspective are much needed in this area.

onflict of interest statement

None of the authors have any personal or financial conflictf interest in relation to this study/paper.

cknowledgements

We would like to thank The BUPA Foundation (the medi-al charity) for their generous support of this research project.

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e would also like to thank all the patients who contributedheir views and time to this study.

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