Extended literature review: Evaluation of Patient Satisfaction with Podiatric

Surgery

Sarah O’Connor

BSc (Honours) Podiatry

Division of Podiatry Centre for Healthcare Education

Faculty of Applied Sciences University College Northampton

Submitted May 2004

Abstract

This paper reviews literature in the area relating to podiatric surgery and patient satisfaction.

Reasoning behind this research is to gauge patient satisfaction with podiatric surgery and to

assess both positive and negatives aspects of the surgical process, which included pre, intra and

post operative phases. Research papers were searched for manually through journals and

electronically via research engines. They were then examined and critiqued using a standardized

critiquing method. There is a lack of research in this area nevertheless the research that has

taken place has shown patient satisfaction to be high.

Acknowledgements

Many thanks to Mr Paul Beeson my Dissertation Supervisor for all the help and suggestions that

you have given.

Appreciation also to Mr Mike Curran and Miss Sharon Rees for all the additional help that you

have supplied.

I would like to thank my family, in particular my parents for all their encouragement care and

support throughout.

Finally I would like to thank Ms Nuala Winston for all the help that you have given.

Contents

Page number

Abstract ii

Acknowledgements iii

Contents iv

Chapter 1 Introduction 1

Chapter 2 Research Strategy 5

Chapter 3 Literature Review 6

Chapter 4 Discussion 38

Chapter 5 Conclusion 43

References 44

Bibliography 47

Appendices 48

Chapter 1

Introduction

Podiatric surgery is elective surgery on the foot and ankle. This involves surgery on bones distal

to the Malleoli and soft tissue of the foot.

Surgery is performed under local anaesthetic with the use of either an ankle or digital tourniquet

on a day case basis by a specialist podiatrist. Podiatric surgery is of great use and value, as it is

performed on a selected area by specialist surgeons and the day case basis makes it cost

effective, as the use of beds is not required. Bligh & Rice (1997) state that “Doctors in the UK

have started to refer more patients to podiatrists for day case foot surgery” and the benefits of

podiatric surgery may be the reasons behind this.

There are three phases involved in the management of the surgical patient; pre-operative, intra-

operative and post-operative. Each of these processes are assessed (see appendices 1-3)

A pre-operative evaluation of the patient is needed before surgery is considered and will include

history taking and a physical examination. This is to ensure that the patient is eligible for surgery

and does not have any risk factors that will affect the post-operative outcome. As a result of this

evaluation, further investigations such as x-rays and blood tests may be indicated.

The pre-operative evaluation should start with the chief complaint and the patient’s reasons for

wanting surgery. Next, the patients past medical history should be reviewed along with each of

the patient’s medical conditions if applicable. After this, a neurological assessment should be

carried out and the patient’s mental history should be considered. Next, a review of any allergies

that the patient may have and the medication that the patient may be taking should take place. A

social history of the patient is then undertaken and once all of these have been assessed, a

physical examination should be performed.

On completion of the history and physical examination an evaluation of risk factors should be

performed. Skully et al (2003) suggests that these “should include the patient’s age, social,

mental, and physical status, and the general patient evaluation”.

Janis (2003) states, “After each patient’s physical, psychological, social and employment needs

have been evaluated, a treatment program can then be designed which will set course for a

successful outcome”. This program should be discussed at length with the patient until the patient

feels completely certain about the impending surgery. Part of the discussion should include

details of the proposed procedure to be carried out, a description of how the procedure will be

carried out, what having the procedure will entail, what is hoped to be achieved by the surgery

and what the patient is expected to do in order to achieve a positive outcome.

Additionally a letter is sent to the patients General Practitioner before surgery has taken place

explaining what is proposed to be done surgically to the patient.

The intra-operative considerations include the type of anaesthetic to be used, the amount of

anaesthetic to be used, and how the anaesthetic is given to the patient. The site preparation

should also be considered and planned. This will entail the positioning of the patient and the foot

including isolation of the foot. The foot should then be cleaned with a sufficient antiseptic such as

iodine. After the previous has been carried out, the surgeon should then consider if the materials

to be used such as sutures and metals used in internal fixation are appropriate for the patient. As

well as making sure that these aspects are appropriate for the patient, the actual procedure

should be deemed suitable for that specific patient. Once the procedure has been performed,

thought should be given to haemostasis and the return of blood supply to the operative area.

Medic alert stickers are placed on notes for the patients that have any allergies or other medical

problems of relevance. Additionally there is a form for all operative details ie local anaesthetic,

tourniquet time, blood pressure etc so that all of these details can be documented.

Once surgery has been performed, a post-operative management plan should be carried out and

a series of appointments will be required to maintain effective patient care. The patient should

also be made to understand all that is required of them to enhance a successful outcome for their

surgery. This involves advice about the surgical site including the cleaning and protection of the

site and signs and symptoms of abnormalities in the area. In addition, the patient will need to be

advised on post-operative pain and analgesia.

An operative summery is taken which is then filed with the patient’s notes post-operatively for

documentation. Additional letters are then sent to the patients General Practitioner after surgery

has taken place. This occurs two weeks post-operatively when sutures have been removed. Four

weeks post-operatively when x-rays have been taken and three months post-operatively when

the patient has been discharged.

Both the patient and surgeon will have ideas of what makes a positive outcome regarding

surgery. Althof & Beasley (2003) argue that, ”Positive results from surgery involve the long term

improvement in the patient’s pain and overall function”.

The justification for carrying out this literature review is that by identifying both positive and

negative aspects of the surgical process, components of the surgical process can be enhanced.

Once these have been highlighted, the quality of service provided by the surgeons in the podiatric

profession can be improved. There is a lack of evidence in the podiatric field regarding patient

satisfaction and their experiences of surgery as few studies have been carried out with the sole

aim of assessing and measuring these.

The aim of this study is hoped to gauge patient satisfaction with podiatric surgery. This will

include patient expectations of podiatric surgery, patient perceptions of podiatric surgery, patient

experiences of podiatric surgery and patient quality of life following podiatric surgery.

All papers will be critiqued using a standard critical evaluation of research, format. Gould (1994)

suggests that this should include assessing whether each paper contains an abstract or

summary, an introduction, a literature review either separately or contained in the introduction, a

methodology, a results section, a discussion, a conclusion and a reference section. After this

each section will be assessed further to, determine whether the content of each section is

deemed adequate based upon a methodological assessment.

Chapter 2

Research Strategy

The research strategy involved searching for papers both manually and electronically. The

manual search of papers was undertaken by looking through journals that had a connection with

podiatric surgery. These journals included the British Journal of Podiatry, British Medical Journal,

British Journal of Podiatric Medicine and Surgery, Clinics in Podiatric Medicine, Foot and Ankle

International, Journal of Foot and Ankle Surgery, Journal of British Podiatry, Journal of British

Podiatric Medicine, Podiatry Now and The Foot. The electronic search took place on databases,

which included Amed, Cinahl, Embase, Medline, Science Direct, Swetwise, Web of Knowledge

and Zetoc all of which store medical papers. Searching this way meant that papers were found

that were full text papers or abstracts taken from full text papers.

When abstracts were found both the reference and the source of that paper were provided. This

meant that the articles were searched for either manually or electronically on databases that

stored full text papers such as Lancet. When papers were not found by these means the Nursing

Union List of Journals (NULJ) and Inter Library Loan Systems were used. If the papers were

available on the NULJ system then the papers were ordered from here first. If they were not

available from this system then they were ordered from the Inter Library Loan System.

Chapter 3

Literature review

Bellocosa & Pollack (1993) entitled patient’s expectations of elective foot and ankle surgery.

The abstract of the paper was deficient as it was not labelled and failed to state the purpose of

the study. However description of how the study was undertaken and a brief mention of the

results were given.

The next chapter of the paper was mediocre. The authors failed to give a heading to this section

and any justifications for carrying out this piece of research. This chapter was presumed to be the

introduction, as the papers aims and objectives were presented here which were, to determine

patient’s expectations of elective foot surgery and to assess the level of fulfilment and satisfaction

of those expectations. This section of the paper also contained literature. However the Authors

state that there is a lack of literature in this area so offered literature from other fields in the

medical profession regarding elective surgery and expectations and satisfaction.

The authors reporting of the methodology was inadequate. There was a failure to mention both

the study’s sample and research design. Consequently it was not known how many participants

were involved in the study or whether the format for the study had been borrowed or self-

designed. Nevertheless the authors did describe the tools used in the study even though their

description of how the study was undertaken was vague. The study was a two-part questionnaire

with the first questionnaire given pre-operatively and the second questionnaire post-operatively to

subjects. The authors, however, did not mention if the questionnaires had been either piloted or

validated to determine its accuracy. The authors also failed to mention any ethical considerations

given to the study to ensure confidentiality and safety of the subjects.

The result’s section of the paper was adequate. It stated how many questionnaires were

completed but failed to mention the response rate of the study. Nevertheless the sample size

used in the study was adequate with 73 subjects being used. The authors also gave information

about the participants giving both the mean and range of the subject’s sex and age. Findings

were presented in the form of text and tables with all tables being labelled appropriately. However

analysis of the results was not explained. Results presented by the authors were dependent on

the question asked. Open-ended questions were presented in tables while close-ended questions

were described in the text and presented in the form of percentages with it stating that 99% of

participants were satisfied with the results of their surgery.

The next chapter was poor and was the discussion section of the paper. There was a discussion

of their findings but the study failed to compare these findings to others. However the authors did

compare the results of the two questionnaires discussing expectations pre-operatively with

satisfaction post-operatively. This aspect of the discussion and study was excellent. However this

process was not mentioned either in the aims and objectives of the study or the methodology.

Also any difficulties encountered in the study were not accounted for here either.

The conclusion in this study was adequate. It discussed and made comment upon the findings

obtained. The conclusions made by the authors were that 99% of patients were satisfied with

their post-operative outcomes and that pre-operative concerns revolved around pain, swelling

and recovery. However the authors failed to give suggestions of further research that could be

carried out in this area.

The references in this paper were styled in the Vancouver system of referencing. The number of

references was sparse and did not come from podiatric journals and as a result of this the

references may not be relevant to podiatry. The references however were from variable sources

and appeared appropriately when displayed in the text.

The overall view of this paper was that it was adequate. The authors answered the research

questions that were posed in the beginning of the paper and achieved a high level of patient

satisfaction in the results. The adequate sample size of the study gave validity to the findings but

flaws in the methodology or reporting of the methodology means that the results obtained have to

be queried.

Tollafield (1993) carried out a Podiatric Surgical audit.

The abstract was excellent; it was clear and concise and contained all information required for

this section of the paper. These included the purpose of the study, description of how the study

was carried out and results obtained from the study.

The introduction was adequate. Background information was given along with acknowledgement

of others work in the podiatric profession but not specific to surgery. The introduction also had

justifications for the research but failed to give any aims for the research.

Tying in with the unorthodox layout of the study the aim was presented in a separate section,

which was to determine whether the practice of podiatric surgical procedures was successful. In

this chapter the author also gave explanations of problems faced regarding this area of podiatry.

The methodology chapter was poor. The general research design and sample design was not

commented upon. The authors did explain the method and tools used in the study. Postal

questionnaires were sent to patients who had received podiatric surgery in a specific time span

and a second questionnaire was sent to local General Practitioners to determine the performance

of podiatric surgical procedures. However there was a lack of information regarding the

questionnaires used in terms of the questions and details included in these. In addition there was

a lack of information about validation and reliability of the questionnaires. The authors also failed

to comment upon the response rate for the study and reasons for non-participation.

The result section was adequate with results being broken down into two parts formed from the

two questionnaires. In this section the response rate for both questionnaires was given with 112

General Practitioners and 175 patients participating in the study but reasons for non-participation

in the study were not stated. The results from the questionnaires were discussed but statistical

analysis of these findings was not described. Results were displayed in either a pi chart or

standard graphs both being adequately labelled and results being presented in percentages.

Results presented were that 90% of subjects believed that an improvement in their condition had

occurred.

The conclusion was sufficient with the author drawing conclusions from the findings obtained in

the study. These were that the performance by specialists in podiatric surgical procedures

appears to be very satisfactory on the basis of the study presented. The author also made

comparisons to others work which both agreed with and refuted these findings. However this has

been included in the wrong chapter and should have been discussed in the discussion section.

The author did, nevertheless, suggest that further research needed to be carried out in this area

to improve the standard of care available but failed to suggest ways in which this could be

achieved.

The reference style displayed in this paper was the Vancouver style of referencing. The author

used a vast amount of references from a considerable number of sources. The references were

relevant, up to date and were used appropriately in the text.

This study was convincing and produced good results in terms of patient satisfaction. The author

answered the research questions posed in terms of determining whether the practice of surgical

procedures was successful. However the author stated that measurement of the success of the

procedure would be based upon patient satisfaction but the author failed to state how satisfaction

was defined and what level of satisfaction was required to be achieved in order to deem the result

as satisfactory.

A patient audit following Podiatric Surgery by Tagoe (1994).

This paper had an unorthodox layout with an abstract or summary at the beginning of the report

not being present.

The introduction was mediocre with no justification for research or literature being presented.

The author however stated the aim of the research with this being to substantiate the claim that

podiatric surgery has produced consistently high patient satisfaction.

The methodology was inadequate, as this was not carried out in great detail giving only an

explanation of what occurred, with a questionnaire being sent to participants post-operatively.

There was no mention of the research design, validation of the questionnaire or response rate of

the study. However the author did state that the use of the questionnaire had been approved but

the author failed to state any ethical considerations that may have occurred to ensure patient

consent and confidentiality. There was also a lack of information about the sample design with

the number of participants, the age and gender of the participants not being stated. However

there was a separate section that gave the response rate of the study and stated that 223

subjects participated in the study but there was no explanation of non-participation. The author

also failed to describe any statistical analysis used on the findings. Results were satisfactory with

what seems like results being given from all questions. The results were displayed in a table, a

graph or pi chart with 72.2% being very satisfied and 21.2% being satisfied with podiatric surgery.

Each result was discussed in length and occurred, as there was no separate discussion chapter.

Due to they’re not being a discussion section, comparisons of others findings were not made.

The conclusion was mediocre and lacked justification. Statements were made, which were that

the service provides a consistently high degree of satisfaction with surgical outcomes, waiting

times and patient care. But the author failed to mention any additional research that could be

carried out to further substantiate these claims.

There were no references used in this paper throughout to justify any of the statements made and

as a result there was no reference section.

The study as a whole was competent. The reporting of the methodology was poor which could

hinder the significance of the results obtained from the study. However aspects of the study were

positive as it showed which aspects of the surgical process patients were satisfied or dissatisfied

with. This is of great benefit to podiatric surgery as it has shown some of the aspects of the

surgical process that could be improved.

Tollafield & Parmar (1994) setting standards for day care Foot Surgery.

The summary of the paper was poor. The authors failed to mention the results obtained from the

study and the purpose for carrying out the study. The authors did however give an explanation of

how the study was undertaken.

The introduction was insufficient as a justification for performing the study was not given and a

hypothesis or the aims and objectives were not stated either. The author did however present and

make reference to others work.

The methodology was adequate but it failed to state the research and subject design of the study.

The authors did explain that a postal questionnaire was sent to both patients and General

Practitioners with the aim of measuring General Practitioners attitudes towards podiatric surgery

and patient’s attitudes towards the level of care that they received. The authors also stated that

the aim of the study was to measure the hypothesis that Podiatric Surgeons could perform

surgery safely.

The result section and the discussion of the results were presented as one. This is not how

papers are traditionally presented but nevertheless this section of the paper was satisfactory. The

response rate and reasons for non-participation were given, as were the characteristics of the

subjects with the average and range of the subject’s gender and age being stated. The results

given were presented separately with the findings being split into General Practitioner results and

patient results. Results from each question posed to both sets of subjects were stated and

discussed. Results showed that 62% of General Practitioners referred patients for podiatric

surgery and that 75% of patients were satisfied with their surgery. These results were also

expressed in the form of graphs and pi charts that were accurately labelled. In addition to the

authors presenting the results and discussion sections together there was also a failure to

present a separate conclusion section. As a result conclusions were drawn in this chapter of the

paper with the authors suggesting that the measurement of patient satisfaction was difficult and

refers to the suggestion that both the patient and the clinician should measure satisfaction.

The referencing in this paper was completed in the Vancouver system of referencing. The

references were used appropriately and were correctly placed in the text. The number of

references used was substantial and were from a variety of sources. The references were also up

to date and relevant to the subject area.

The overall view of the study was that it was sufficient. The authors stated a hypothesis but failed

to state a null hypothesis for the study. Also even though a hypothesis was given statistical

analysis to determine whether this hypothesis should be accepted or rejected was not performed

therefore giving uncertainty to the results obtained. The authors do however break down each of

the questions asked and as a result show which aspects in terms of pre, intra or post-operative

aspects of the surgical process that the patients are not satisfied with.

A clinical audit by Vohra (1995).

There was no labelling of the first chapter of the study. This section contained a brief statement

about podiatric surgery and stated the aims of this study, which were to monitor and measure

patient satisfaction and the level of surgical care delivered by the surgical podiatry department. If

this section was to be the abstract or summary then a purpose for carrying out the study should

have been given along with how the study was undertaken and results obtained from the study.

However these were not stated.

There was then a separate chapter that was labelled the purpose of the study and this section did

give in depth reasons for carrying out the research.

The next chapter should have been the introduction. This section however was not present

indicating that there was no justification for carrying out the research or the presentation of

literature in this area.

The methodology section was inadequate. There was no explanation of the research or sample

design, with the author only stating how the study was undertaken. This was that a postal

questionnaire was sent to subjects post-operatively. There was no mention of the survey used or

the questions asked in this survey. In terms of the subjects, their age and gender was not

commented upon, neither were any ethical considerations that the author faced. The number of

questionnaires sent to patients was given but the response rate was not stated.

The response rate however was given in the next section of the study with 160 subjects

participating in the study. This chapter was the results and discussion section of the paper and

was inadequate. The results were given for each question asked and a labelled graph was

presented for each question. Each question and its results were presented and discussed but

statistical analysis of each result was not discussed. The result of patient satisfaction given was

that over 90% felt satisfied with the results of their surgery. Although each response was

discussed this failed to meet the standards of a discussion section as there were no comparisons

made between the authors findings and previous findings.

The conclusion was reasonable with conclusions being drawn that patient satisfaction was high.

Additionally the author made suggestions of further research to be carried out in this area.

There was no use of references throughout this paper and therefore there was no reference

section in the paper. This meant that the author was not up to date with information in this area.

The author answered the research questions in terms of patient satisfaction. However the

methodology and analysis of the results hinders the validity of the findings. The author also failed

to use literature in the paper, which meant that the author was unaware of findings and theories in

this area.

Laxton (1996) a clinical audit of Forefoot Surgery performed by registered Medical Practitioners

and Podiatrists.

The abstract was excellent containing a purpose for carrying out the study, the method used to

carry out this study and findings obtained from the study.

The introduction was insufficient. The author only gave a justification for carrying out the research

and failed to present adequate literature on this subject or give a hypothesis or state the aims and

objectives for this study.

The methodology was adequate with the method and the questionnaires used along with the

number of subjects asked to participate in the study all being described. The author does not

however expand on the subject or research designs. The author also explains in great detail that

results will be achieved by Podiatrists, General Practitioners, General Surgeons and Orthopaedic

Surgeons all giving their own acceptable standard of patient satisfaction, with the author then

averaging these standards to assess findings. The analysis of results was discussed further with

the author stating that comparisons of Podiatrists results would be made against the results of

General Practitioners, Orthopaedic Surgeons and General Surgeons in terms of nail surgery and

that Podiatric results would be compared to Orthopaedic results with regard to forefoot surgery.

The result’s chapter was satisfactory and was split into two sections. The first was nail surgery

and the second being forefoot surgery. For both sections the response rate and reasons for non-

participation were given. The number of subjects participating in the study was 239 General

Practitioners, 9 General Surgeons, 12 Orthopaedic Surgeons and 5 Podiatrists. Results showed

that for nail surgery patient’s satisfaction was 85% with satisfaction levels for forefoot surgery

being 73%.

The discussion was constructive but had aspects of the conclusion in it, as there was no separate

conclusion section. The author draws conclusions about the results obtained which were that

Podiatric Surgeon’s reached an acceptable standard. The author also critiques the methodology

that was used to obtain these findings and suggests that interpretation and clinical validity of

results was hampered by insufficient sample sizes. The author did not compare findings to others

but stated that there was a lack of literature to be able to do so. There were also suggestions for

further research to support these findings.

The reference style of this paper was the Vancouver style of referencing. The amount and

significance of the references, which were up to date, was sufficient. Additionally they were

displayed accurately in the text.

The standard of the study overall was sufficient. The author states that results obtained by

Podiatric Surgeons regarding patient satisfaction was high and exceeded results of other

professions. However these findings can be questioned as even though findings obtained from

podiatric surgery were above the mean acceptable standard set by all professions, the

acceptable standard set for podiatry was not noted. Findings could therefore have been below the

set standard for podiatric surgery and as a result patient satisfaction in this study may not have

met the required standard.

Rees & Tagoe (1997) carried out a complication audit and patient satisfaction survey following

Podiatric Surgery.

There was no summary at the beginning of the paper so a brief overview of the purpose of the

study, how the study was carried out and findings from the study was not given.

The first chapter was the introduction, which was sufficient. This section contained both

justifications for carrying out the research and the aims of the study. The aims stated were to

identify risk factors for complications and to evaluate patient satisfaction. The author however did

not review literature in this area.

The methodology was inadequate with the author only stating how many subjects were recruited

for the study, which were 177. The author failed to mention the research design and the subject

design with no explanation of how the study was undertaken.

The results section was adequate with each section of the survey being broken down and results

stated and labelled graphs being displayed. The author failed to comment on any statistical

analysis used on the findings with results being displayed as percentages. The results stated

show that 82.2% of the patients showed satisfaction with results of their surgery.

The results were discussed in full in the discussion section. The author also compared the

findings to those of others, which were in support of the author’s results. This section also

benefited from the author’s explanation of negative and inaccurate results.

The conclusion section was also sufficient as statements and conclusions were made along with

suggestions of work that could be carried out to improve and support the author’s findings.

The referencing of the paper was completed in the Vancouver style of referencing. The number of

references used was sparse but the quality was sufficient, as they were relevant, up to date and

from a variety of sources. The references used were displayed in the paper adequately.

The overall view of this paper was satisfactory. The reporting of the methodology used to

undertake the study was vague and as a result the findings could have been affected. However

the results obtained from the study were of benefit and the reporting and discussion of these was

done in great detail with the use of literature to support these.

A study by Ashford et al (2000) entitled a retrospective analysis of Swanson Silastic Double

Stemmed Great Toe Implants with Titanium Grommets following Podiatric Surgery for Arthritic

Joint Disease.

The summary of the study was acceptable. It contained all that was required with the authors

stating a purpose for carrying out the research, how the study was undertaken and results

obtained from the research. The summary also stated that ethical approval was sought and

granted for this piece of research. This was well reported but should have been reported in the

methodology section of the paper.

The introduction was good and contained a vast amount of background information about the

subject. The authors stated the aim of the study, which was to analyse the Swanson total implant

Arthroplasty with respect to pain levels, physiological function and quality of life. The introduction

also contained literature from others in this field.

The methodology section was sufficient. It stated what took place, were it took place and who

participated in the study. The method of the study was a questionnaire using the podiatric audit in

surgical and clinical outcome measurement system (PASCOM) followed by an interview and a

clinical examination of the subject, with the latter two focusing on the pain levels and

physiological functions of the subjects. As the PASCOM system was used the questionnaire was

validated and reliable but the authors do not state this. The methodology also stated the

inclusion and exclusion criteria of the subjects. The authors also gave the number of subjects

participating in the study along with the average age of the subjects and their gender. Despite

this it does not state the response rate for the study in this chapter.

The response rate and number of participants, which was 20, was given in the result section and

the authors also stated reasons for non-participation. Analysis of the results was not described

but was presented in the form of percentages. It was not noted whether all results were given or if

results were selected. Findings showed that 62.5% were very satisfied with their surgery while no

subjects stated that they were dissatisfied. The result section of this paper was therefore

sufficient.

The discussion section was also adequate with description of the analysis used on the author’s

findings. A one tailed Wilcoxin statistical test was carried out on pain and activity level results.

The authors stated that there was a significant relief in pain. From the statistical test it was found

that this had a level of significance of p<0.005. The activity levels were found to be significantly

increased, and statistical analysis showed that the level of significance was p<0.005. In this

section the authors also compared their findings to those of others, which agreed with their

findings.

The conclusion states that there was an improvement in the patient’s quality of life. However

results to support these were not presented here or previously. The authors also failed to

suggest ways in which this research could be improved and to expand upon existing knowledge.

The reference style of the paper was Vancouver and the number of references used was

substantial and from a variety of sources. The sources were of good quality and were relevant

and up to date.

The overall view of this study was that it was a satisfactory piece of research. The author fulfilled

the aim of the study by determining the patient’s quality of life following podiatric surgery. A

hypothesis was not given for this study and yet statistical analysis of findings was performed. The

analysis of results found that the level of significance was p<0.005 and as a result the hypothesis

if it had been presented could have been accepted. The analysis used and the results of this

analysis was neither explained nor justified and as a result reliability of the results is

compromised.

A study by Kilmartin (2000) on a review of: activity, surgical outcomes and patient satisfaction

over a 27month period.

The abstract was poor with the author failing to state the purpose of the study and how it was

undertaken with only the results established being stated.

The introduction was also inadequate with only background information and a justification being

given. The author failed to state a hypothesis or give aims and objectives for the research along

with an absence of evaluation of other research on this topic.

The next chapter ought to have been the methodology but this was absent. However the author

did state the method used to carry out the research, which included using two measuring tools.

The first was a clinical rating system that was given pre and post-operatively to subjects. The

American orthopaedic foot and ankle society developed the rating system (AOFAS) and therefore

it is presumed that the research design had been borrowed and validated but the author failed to

state that this was the case. The second tool was a questionnaire. The author failed however to

state whether this had been self designed or borrowed or whether it had been validated and

therefore reliable. Along with the failure to report on the research design the author also failed to

mention the subject design.

The result’s section of the paper was adequate. The results of the clinical rating scale and the

survey were presented in tables that were adequately labelled. These showed that 91% of

patients were satisfied with the results of their surgery. Analysis of the results was not explained

and was presented in the form of percentages or the mean score. The author also stated the

response rate of the study but failed to gives reasons for non-participation.

In the discussion the author poses questions about research in this area but fails to make

comparisons with others work or inform of any difficulties encountered while carrying out the

research. For these reasons the discussion was deemed inadequate

The conclusion was however sufficient with statements and conclusions being made which was

that podiatric surgery was safe, effective and popular. The author also gave suggestions of

further research that could aid these.

The style of referencing used in this paper was that of the Vancouver system. The quality of

referencing in this paper was satisfactory and they were used appropriately throughout the text.

The number of references was appropriate and they were relevant, up to date and from various

sources.

A hypothesis for the study was not given, neither were any aims or objectives. As the author did

not have any research questions at the beginning of the research it is difficult to ascertain what

was wished to be achieved from the research and what conclusions were hoped to be obtained

on completion of the research.

In a study by Bennett et al (2001) entitled health related quality of life following Podiatric Surgery.

The abstract or summary of the paper was not labelled but its content was satisfactory. This

section did not contain the purpose for carrying out the study but did give a brief overview of how

the study was undertaken and the results obtained from the study. The authors also stated new

findings, which gave validity to their findings. These new findings were that there is an advantage

in assessing health related quality of life as opposed to patient satisfaction.

The next chapter was not labelled and was inadequate. This section contained a justification for

carrying out the research and literature was presented in this section also but it was not specific

or relevant to the research topic. The authors also failed to state the aims and objectives of the

study or give a hypothesis to be tested by the research.

The research and subject designs are not noted here in the methodology section. The method

used was the recruitment of subjects who met the selection criteria. However the authors failed to

mention whether this was done randomly or by selection. The inclusion criteria mentioned was

not described and details of what this involved were not given. This also applied for the exclusion

criteria of the study. The tools used to measure the outcomes of podiatric surgery were

described. This included using two measuring tools. The first was the foot health status

questionnaire (FHSQ) and the second was the short form 36 questionnaire (SF-36). In this

section the authors also state the aims of the study, which were to establish the patients foot

health status post-operatively and to see to what extent Podiatric Surgeons alter this.

The result’s section was adequate and gave explanations of non-participation. The number of

participants was 140 and their characteristics regarding gender and age were also given. It was

stated that the questionnaires used were used to evaluate whether health related quality of life

changes over time. Results were compared with those of a validated study group and it was

explained that these findings from the validated group were used to calculate the acceptable

standard. Results from the survey were presented in the form of graphs and not referred to in the

text. The graphs showed that subject’s general foot health perception scores all increased post-

operatively and were above the acceptable score given from the validated group. The results of

the SF36 gave differing results to that of the FHSQ with regard to patient quality of life. The

results from the FHSQ were more positive than the SF36 results with the FHSQ giving higher

levels of satisfaction.

The discussion section was adequate with the authors comparing findings to others, which

agreed with their research, and as a result gave validity to their findings. The findings from this

study were compared to each other also with findings from the patient satisfaction surveys being

compared to that of the quality of life outcomes. The authors also stated and showed that

statistical analysis was used on the findings in the form of analysis of variance (ANOVA).

However how and why this was used is not discussed either here or previously in the

methodology section.

The conclusion section was sufficient. The authors concluded that subjects experienced

significant post-operative improvements across a range of health related quality of life parameters

and that the use of patient satisfaction surveys leads to an underreporting of the benefits of foot

surgery. The authors however fail to mention any suggestions of further research that could be

carried out to verify these findings.

The referencing of this study was that of the Vancouver style and the references used in this

paper were up to date and relevant. Additionally the number of references used was satisfactory

and from a number of sources. The references used in the paper were appropriate for the study

and displayed appropriately throughout the text.

The overall view of this study was adequate, with the content of the paper in general being

satisfactory. The authors do however state that the quality of life surveys are better than patient

satisfaction surveys, as patient satisfaction surveys leads to underreporting of the benefits of

podiatric surgery. This aspect of the paper was valuable, but as the reporting of the methodology

and statistical analysis used in the study was inadequate, this could have lead to the

interpretation of the results being inaccurate. As a result the findings from the health related

quality of life surveys could have been overestimated leading to a distortion of the results.

Kilmartin (2001) an audit of Podiatric Surgery in a community trust; a review of activity, Surgical

outcomes, complications and patient satisfaction over a 4 year period.

The abstract or summary was not labelled and a purpose for carrying out the study was not given.

However there was a brief description of how the study was undertaken along with the results

obtained from the study. As a result this section of the paper was satisfactory.

The introduction was adequate as it gave a justification for carrying out the research. It also gave

background information in this area and presented work of others. However a hypothesis or aims

and objectives were not given.

The methodology was mediocre, as it did not contain a subject or research design. The method

used in the study was described. This included using the AOFAS clinical rating scale pre and

post-operatively, along with two questionnaires, given to the subjects post-operatively to measure

complications and patient satisfaction. The tools used to measure the outcomes had been

borrowed and therefore validated in the case of the clinical rating system but it was not mentioned

whether the questionnaires had been borrowed or self designed.

The results showed that 93% of the subjects were happy with the results of their surgery.

Statistical analysis of the results was performed, calculating the mean and standard deviation of

the results. There was also a paired t test carried out that showed the findings to be p<0.001.

This however was not explained and was inadequately presented. The authors also stated the

response rate of each of the questionnaires but failed to give reasons for non-participation.

The discussion chapter was adequate with the authors making comparisons to others work which

agreed with the author’s findings. The author also made suggestions of additional research to be

carried out to improve the research in this area.

In the conclusion the author gave a review of findings, which were that podiatric surgery was

safe, effective and popular and was deemed sufficient.

The reference style of this paper was that of the Vancouver style of referencing. The number of

references used was sufficient and from a number of sources. The references were of quality as

they were relevant and up to date.

As a hypothesis was not given it is not known what was proposed in terms of measurement and

findings and consequently it is not known if the authors research questions and aims were

answered on completion of the research. In addition though the level of significance was p<0.001

which meant that the hypothesis could be accepted, as there was no hypothesis in the paper the

level of significance is insignificant. Reasoning for the use of the statistical test was not given and

findings of these tests were not explained. As a result there is a lack of clarity of the findings.

Tollafeild (2001) an audit of lesser Metatarsal Osteotomy by Capital Proximal Displacement.

The abstract was adequate stating the aim for carrying out the research, giving description of how

the study was undertaken and the results acquired from this research.

In the introduction the author presented background information about the surgery and findings

and opinions from others. Along with this a justification for carrying out the research was given.

The aims of the study, which was to evaluate the rate of success of the surgery based upon

patient satisfaction, were included. A hypothesis was also given that Proximal Displacement

Osteotomies (PDO) provides better or worse results than other Osteotomies. All aspects of the

introduction were covered so this section was satisfactory.

The methodology stated what was to occur in the study in terms of the operation to be performed

and the tools used to measure the rate of patient satisfaction. The methodology also stated that

36 subjects participated in the study and gave the range of subject’s age and the gender of the

participants, which was broken down into percentages. The PASCOM system was used to

measure patient satisfaction and the author described how this tool was to be used. The author

also stated that the measurement of the PDO was to be carried out and that the patient’s mobility

of the joint and internal fixation of the joint would determine these results. Due to the information

offered here the methodology was deemed sufficient but the author did fail to describe both the

research and subject design in full.

In the results section the author stated that PDO scores were analysed using the U Mann

Whitney statistical test. The author reported that the findings from the statistical test showed that

there was no significance. However the exact figures that were found were not reported.

The discussion section nevertheless was adequate with the author comparing findings to those of

others but failing to comment upon the methodology used and any difficulties that may have been

encountered while using this methodology.

In the conclusion section the author states that PDO fares better or as well as other Osteotomies

and makes recommendations for further research.

The reference section was completed in the Vancouver style and was done in an appropriate way

throughout the text. There was a useful quantity of references, which were from a various number

of sources and were relevant and up to date.

The author stated in the conclusion that PDO gave better or similar results in terms of patient

satisfaction in comparison to other Osteotomies. However analysis of other Osteotomies was not

performed or given by the author and as a result the author cannot substantiate the claims that

PDO gives greater patient satisfaction. Also analysis used on PDO findings was found not to

have any significance and as a result the hypothesis that PDO gives better or similar results

should be rejected. The use of the analysis and the findings was not explained or justified and as

a result the validity of the findings is questionable. The authors also stated that patient

satisfaction was to be measured in this paper yet there was a failure to present this and as a

result the author did not answer the research questions posed at the beginning of the research.

A study by Kilmartin (2002) entitled revision of failed foot surgery.

The abstract was adequate but was not labelled. It contained a purpose for carrying out the

research. Both results and new findings that emerged from the research were stated but the

authors did not mention how the study was carried out.

The introduction was not labelled either but was also adequate. It contained a justification for the

research and the aims of the study, which was to find the causes of patient’s dissatisfaction

following foot surgery. The author also used literature to support the justification and aims given

for the research.

The reporting of the methodology was poor with the authors giving no mention of both the

research and subject designs. The methodology did state what was to occur with subjects being

given a questionnaire at their last post-operative appointment to assess their satisfaction rate with

revision surgery.

The results section stated the response rate of the study and that 176 subjects participated in the

study along with the age and gender of participants. Statistical analysis of the findings was not

discussed but described, with 69% of participants being completely satisfied with their revision

surgery while 6% were dissatisfied.

The discussion section was sufficient with authors giving an in depth analysis of their findings and

reasons for these to occur. In addition the author uses others findings to support their own.

The conclusion was insufficient with the authors making a statement that the patients who

underwent revision surgery achieved high levels of satisfaction but did not expand on or give

justifications for this statement. Also the author failed to suggest new methods in which these

findings could be substantiated.

The reference style used in this paper was the Vancouver system of referencing and the numbers

of references were vast and were from a number of sources. Additionally the references were

relevant and up to date.

The study overall was satisfactory with the research questions and aims being fulfilled. The

results were sufficient but a better reporting of the methodology and analysis of the findings would

have given greater validity to the results.

O’Kane & Kilmartin (2002) looked at the Surgical Management of Central Metatarsalgia.

The abstract was inadequate with the author only stating the results of the research and failing to

mention how the study was carried out and the purpose for carrying out this research.

The introduction was insufficient. It contained background information and highlighted work of

others but failed to give a justification for carrying out the research or state a hypothesis for the

study or its aims and objectives. However the author’s state that the Weil Osteotomy is used as

the surgical technique as it produces better results and as a result better patient satisfaction.

The methodology did not state the research design and the authors failed to state the inclusion

and exclusion criteria for the study. But a description of how the study was undertaken was

described. The AOFAS clinical rating scale was used pre and post-operatively which measured

pain, effect of the foot problem on activities, footwear requirements, joint motion, and alignment

and cosmetic appearance. The authors also state that subjects were asked about their level of

satisfaction but it does not mention whether this was apart of the AOFAS clinical rating scale or a

separate questionnaire. The subject design was explained thoroughly with the authors stating that

17 subjects were involved in the study and additionally giving the age and gender of the subjects,

the response rate for the study and reasons for non- participation but with the authors failing to

mention any ethical considerations of the research.

Results obtained from the study were that 85% were completely satisfied and 5% were

dissatisfied with results of their surgery. A statistical test, which was a paired t test, was carried

out and findings were shown to have a significance of p<0.001. How the authors and why the

authors obtained this analysis of the results were not explained. Results were described rather

than interpreted and consequently there was no discussion section present in this paper. This

therefore meant that there was no comparison to others work to support the authors finding.

The conclusion was inadequate with the authors stating that there was a high level of patient

satisfaction but failing to suggest further research to support these claims.

Referencing in this paper was completed in the Vancouver style of referencing. The references

themselves were of good quality and used appropriately throughout the text. The number of

references was small but they were from different sources and were relevant and up to date.

As the aims and objectives of the study were not stated in the paper, it is not known what the

authors intended to measure and aimed to find out from this research. As a result the findings

stated and the conclusions made are of little significance, as it is not understood whether these

were meant to be determined. Also a hypothesis for the research was not given. This therefore

means that statistical analysis of the results was carried out to test a hypothesis that was not

stated. The fact that a description of the statistical analysis used was not given means that the

numbers presented and level of significance do not denote anything. Additionally the authors

state that Weil Osteotomies give greater results and produce a higher level of patient satisfaction.

However the authors fail to give statistics for other Osteotomies to support this statement.

Helm & Ravi (2003) carried out a study looking at Podiatric and Orthopaedic Surgery a customer

satisfaction of General Practitioners.

The abstract of the paper was excellent. It included a rationale for carrying out the research, a

brief explanation of how the study was undertaken and the findings obtained from carrying out

this research. In addition the abstract stated new findings that emerged from the research.

The introduction of the paper was quite satisfactory. It contained a justification for carrying out the

research and stated the aims of the study, which were to ascertain General Practitioners views on

quality of service and the satisfaction of patients following podiatric and orthopaedic surgery. The

authors however presented little literature from this area.

The methodology was poor, as there was no mention of the research design and little on the

subject design. The method itself was explained which involved a questionnaire being sent to

General Practitioners. The response rate of the study and analysis of the results were not

discussed but the authors did state that 129 General Practitioners participated in the study.

Subjects were asked to rank their satisfaction score between 1 – 5 with 1 being poor and 5 being

excellent. The results showed that on average the patient’s satisfaction score was 4.

In the discussion section the authors compared their findings to those of others. Conclusions

were also made in this section, as there was no separate conclusion section. These were that

General Practitioners expressed considerably greater satisfaction with podiatric surgery. However

in this chapter there was no suggestion that further research should be carried out to substantiate

these findings.

The style of referencing was the Vancouver system of referencing. The number of references

used was sparse but they were displayed in the text in a clear and appropriate form. They were

from various sources and were relevant and up to date.

The study as a whole was appropriate. The authors fulfilled the aim of determining the set aims

and objectives of the study. The reporting of the methodology was poor and the methodology

itself had flaws as the authors chose to obtain findings on patient satisfaction from a secondary

source, which could have altered the results given.

A study by Money et al (2003) entitled a retrospective analysis of the Sgarlato Double-Stem

flexible Implant for Arthroplasty of the First Metatarsophalangeal Joint.

The abstract of the section was satisfactory with the authors stating the purpose for undertaking

the research, describing the way in which the study was carried out and stating the results

obtained from the research.

The introduction was adequate with the authors presenting literature in this field and containing a

justification for carrying out this research. The author also stated the aims of the study, which

were to review the results of Implant Arthroplasty using the Sgarlato Double-Stem flexible

Silicone gait Implant with respect to post-operative complications, pain, range of motion, quality of

life and patient satisfaction.

The methodology was sufficient. The authors state that the research would be carried out via the

use of questionnaires. The questionnaires were self designed but the author’s did not state

whether it had been validated or piloted. Additionally the inclusion criterion was given but there

was a failure to report the exclusion criteria for the study. The author’s also failed to report the

subject design of the participants.

The result section was satisfactory. The authors state the response rate for the study and give

reasons for non-participation. The number of subjects participating in this study was 20 and their

age and gender was also given in this section of the paper. The results given showed that 100%

of patient’s activity levels increased and improved post-operatively. The authors also reported a

92% patient satisfaction rate.

The discussion section of the paper was sufficient as the authors discuss their findings and used

literature to support these findings.

The conclusion section was satisfactory. The authors concluded that podiatric surgery produces

high levels of patient satisfaction and makes suggestions of further research to be carried out to

support these findings.

The referencing used throughout the paper was that of the Vancouver style of referencing and

they were used appropriately in the paper. The number of references was satisfactory and they

came from a number of sources. The references were also relevant and up to date.

The overall view of the study was satisfactory. The authors ascertained the aims of the study but

better analysis of results could have been undertaken which would have given more validity to

both the study and its findings.

A study by Rudge & Tollafeild (2003) entitled a critical assessment of a new evaluation tool for

Podiatric Surgical outcome analysis.

The abstract was satisfactory. It explained the purpose of the study and commented briefly on

how the study was undertaken but if failed to mention results obtained from the research.

The introduction was also adequate containing both the author’s justification for the research and

aims of the study. The aim stated was to illustrate the ways in which data could be used. There

was then a section that contained background information and literature on podiatric surgery.

The methodology was sufficient. The research and subject designs were not mentioned but there

was an in depth portrayal of how the study was carried out. This included the subjects receiving

a postal survey six months post-operatively using a patient satisfaction questionnaire that had

been validated. The questionnaire itself was described stating that it was the PASCOM tool,

which was used. There was also a section that described the statistical analysis of the findings

with a non-parametric ranking method being used to analyse the patient satisfaction

questionnaire results.

The result’s section was poor with results being selected and a failure to report patient

satisfaction findings. In this section the authors highlight problems with the results and suggest

new ideas for further research.

The discussion was adequate with the authors stating problems that occurred with the

methodology and data collection. The authors however did not compare their findings with those

of others.

The conclusion was sufficient with a further critique of the methodology occurring but with a

failure to draw conclusions from the research and make suggestions for further research that

could be carried out.

The referencing of this paper was done in the Vancouver style of referencing. There was a vast

amount of references used which came from various sources .The references were relevant and

up to date and were displayed throughout the text in a clear and precise manner.

The overall view of the study was that it was competent and the findings obtained substantiated

the majority of the aims of the study. However although the authors measured patient satisfaction

they failed to highlight or present these in the paper, which meant that some aspects of the

research questions had not been answered in full.

Chapter 4

Discussion

D R Tollafield and T E Kilmartin have mainly contributed to the literature and research in this

area. Together they have formed the vast majority of the research that has been critiqued.

From the literature reviewed it was found that patient satisfaction was high with reported findings

ranging from 62.5% up to 99%. This high level of satisfaction suggests that patients who

underwent elective day case foot surgery are happy with and have confidence in the Podiatric

Surgeons undertaking the operative procedures.

However, within the studies carried out there has to be some level of criticism, regarding the

methodologies used to carry out the studies and the analysis of the findings obtained from these

studies. As a result even though all studies have reported high levels of patient satisfaction there

has to be some questioning of the findings obtained.

The methods used in undertaking the studies were not themselves inadequate. However the

authors reporting of the methodologies that were used were deemed to be insufficient. The lack

of information regarding how the studies were undertaken meant that validity of both the research

and results was questionable, as without such information studies cannot be replicated.

The major criticism of papers has been the author’s analysis of the findings obtained from the

research and the lack of description and justification for undertaking the chosen analysis.

Statistics are needed as they enable the conveying of information and the interpretation of

numbers in an efficient way and allow conclusions to be drawn about situations. The majority of

analysis has been through descriptive statistics with findings presented in the form of averages

and percentages and the mean and standard deviation being used to measure these. The mean

is used to supply a snap shot of a set of numbers but if numbers are widely spread then the

figures can be misleading and not representative of the subjects. The standard deviation is used

in order to give a better impression of a distributions shape as it involves the measure of

dispersion. However the standard deviation allows for a margin of error and as a result it gives a

larger standard deviation and inaccurate findings can occur. Some of the other papers reviewed

used another form of analysis, which involved the use of inferential statistics. In order for these to

be used a hypothesis, which is a theory in which provisional predictions are made, is required and

then the probability of these predictions is measured in order to prove the significance of the

findings. The statistical tests used in the papers reviewed were Wilcoxon, Mann Whitney, paired t

tests and ANOVA. Wilcoxon statistical tests can be used whenever sets of scores are paired off

in some way. Mann Whitney statistical tests can be used when there is no pairing of results.

While t tests are used when samples are normally distributed and when the variances of samples

are similar. ANOVA in which there are many forms is used when testing behavioural or biological

sciences. The tests used in the papers appear to be accurate and selected appropriately.

However their validity is questionable, as there is no explanation or rationalisation for this analysis

to have occurred.

A reason behind the high level of patient satisfaction may be due to the measuring tools selected

and used by the authors. The various tools that were used in the papers reviewed include self-

designed patient satisfaction questionnaires, health related quality of life measurements including

the SF-36 questionnaire and the FHSQ and clinical rating systems such as the AOFAS and

PASCOM. Patient satisfaction surveys are used to evaluate outcomes while health related quality

of life measurements are used when the aim is to measure the patient’s own experiences of their

treatment. Additionally clinical rating systems are used when it is required to combine both

subjective and objective measurements (Wrobel 2000).

It has been suggested that patient satisfaction surveys only capture dimensions of care and not

the patient’s true beliefs. As a result there is a lack of validity regarding the patients level of

expression of satisfaction (Bennett et al 1998). It has been argued that post-operative clinical

rating systems overestimate the benefits of surgery (Toolan et al 2001) and in addition to this

there is an oversimplification of findings obtained from research using this tool (Kitaoka & Patzer

1997). The health related quality of life measurements are the tools that have had the most

positive response in terms of validity and reliability. Bennett et al (1998) states that “the tool

demonstrates a high degree of content, criterion and construct validity and test, retest reliability”.

However Parker et al (2003) suggests “a review of outcome measures used in foot and ankle

surgery research reveals that the issues of validity, reliability and responsiveness of outcome

measures has not been addressed”. If the tools used are neither reliable nor validated, then

inaccuracies in the results could have occurred and as a result, it can be argued whether the

findings from these studies have been deceptive or are in fact an accurate finding. In addition, as

the responsiveness of the measuring tools has been questioned, the tools may not have

measured the patient’s true beliefs of the surgery.

The aim of the research was to gauge patient satisfaction with podiatric surgery. This aspect has

been achieved with papers reporting high levels of patient satisfaction. However, it was also

aimed to assess patient expectations of podiatric surgery. To a certain degree, this has been

achieved as a paper that was critiqued looked at patient expectations of elective foot surgery. The

questionnaires used did not go into great detail so as a result the information presented from this

paper was sparse. Patient quality of life following podiatric surgery was hoped to be assessed

also and the paper that looked at this stated that there was an improvement in patient’s health

related quality of life. However, as only one study has been conducted in this area, it has not

been determined whether these findings are typical. In addition, it was hoped to assess patient

perceptions and experiences of podiatric surgery but this was not accomplished as none of the

papers critiqued looked at these areas. As a result, all of the aspects regarding patient

satisfaction were not achieved. The fact that podiatric surgery and patient satisfaction has not

been previously researched to any great degree has resulted in the amount of detail presented in

this area to be minimal.

Though authors reported high levels of patient satisfaction they failed to suggest the reasons

behind why the remaining subjects were dissatisfied. The lowest figure reported regarding patient

satisfaction was 62.5% and as a result, this meant that nearly 30% of patients who underwent

podiatric surgery were dissatisfied at some level.

Along with the failure to state which aspects of the podiatric surgical process that the patients

were dissatisfied with, there was also a failure to break down the areas in which the patients were

satisfied. This meant that pre, intra and post-operative aspects could have been established but

the majority of studies failed to do so.

The lack of research papers produced in this area was the greatest limitation faced and due to

this it is felt that the findings obtained from the review of the papers could be further substantiated

with additional research.

A reason for the lack of papers in this area could be due to the fact that papers are available but

there was a failure on my behalf to acquire these. This could be because the research strategy

adopted was flawed. Through the use of different search engines and contacting individuals who

may be researching the area could have lead to an increase in the number of papers obtained.

Additionally, the reasons behind this could be that podiatric surgery is a developing profession

and has yet to produce a vast amount of research to aid these claims.

As a result of the rise in the number of elderly people due to increased longevity and a longer life

expectancy, the requirement for podiatric surgery can only increase. This will result in pressures

on podiatrists increasing and as a result, patient caseloads will also increase. In many ways,

much more research should be taking place now in order to accommodate the growing numbers

of patients and to facilitate improved podiatric care.

Chapter 5

Conclusion

Though there has been criticism of the papers reviewed, the conclusions drawn by the authors

that patient satisfaction levels were high are accepted.

The podiatric profession needs more stringent guidelines in research structure in order for it to

make a more valid contribution to improving services.

In the world of Medicine, there is a vast amount of research and literature, but there is a lack of

empirical research in the field of podiatry with the aim of assessing patient satisfaction. This may

be due to the fact that podiatric surgery is a relatively new profession and has yet to develop. As

a result, it is recommended that podiatrists continue to carry out research in this area so that it

can be improved and produce a better service for patients who desire elective foot and ankle

surgery.

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