Preoperative psychological distress no reason to delay total knee arthroplasty: a register-based prospective cohort study of 458 patients

Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study

PURPOSE

The aim of this study was to investigate the influence of preoperative anxiety and depression on subjective function, pain and revision rates following total knee arthroplasty (TKA).

METHODS

A prospective comparative study was conducted, including 349 patients undergoing TKA surgery between January 2019 and April 2021. Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire preoperatively, and a set of Patient-Reported Outcome Measures (PROMs) preoperatively and at 6, 12 and 24 months postoperatively. Patients were categorized into anxiety and depression groups based on HADS scores. PROMs included the Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS) and NRS-Pain. Differences in PROM scores between the anxiety/depression group and, respectively, nonanxiety/nondepression group were assessed, as well as differences in minimal clinical important difference (MCID) and attainment of Patient Acceptable Symptom State (PASS). Lastly, revision rates were compared.

RESULTS

Anxiety and depression groups exhibited inferior subjective function preoperatively and postoperatively compared to nonanxiety and nondepression groups (all p < 0.05), experienced more pain preoperatively (p < 0.001) and also postoperatively for depression patients (all p < 0.05). Significantly fewer patients with anxiety and depression reached the PASS for KOOS-PS, OKS and NRS-Pain (all p < 0.05). There were no differences in the proportion of patients reaching the MCID for all PROMs (all p > 0.060), and revision rates did not differ between groups (both p > 0.96).

CONCLUSION

Preoperative anxiety and depression negatively influence subjective function and pain preoperatively and up to 2-year follow-up in patients undergoing TKA. Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures

BACKGROUND

Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary.

QUESTION/PURPOSE

Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA?

METHODS

The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively.

RESULTS

Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness.

CONCLUSION

Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness.

"I am accustomed to something in my body causing pain": a qualitative study of knee replacement non-improvers' stories of previous painful and stressful experiences

BACKGROUND

Approximately 20% of total knee arthroplasty patients experience persistent postsurgical pain one year after surgery. No qualitative studies have explored previous stories of painful or stressful life experiences in patients experiencing persistent postsurgical pain after total knee replacement. This study aimed to explore stories of previous painful or stressful experiences in life in a cohort of patients that reported no improvement in pain one year after total knee arthroplasty.

METHODS

The study employed an explorative-descriptive qualitative design. Data was collected through semi-structured interviews five to seven years after surgery, with patients who reported no improvement in pain-related interference with walking 12 months after total knee replacement. The data was analyzed using qualitative content analysis.

RESULTS

The sample consisted of 13 women and 10 men with a median age of 67 years at the time of surgery. Prior to surgery, six reported having at least one chronic illness and 16 reported having two or more painful sites. Two main themes were identified in the data analysis: Painful years - the burden of living with long lasting pain, and the burden of living with psychological distress.

CONCLUSIONS

The participants had severe longlasting knee pain as well as longlasting pain in other locations, in addition to experiences of psychologically stressful life events before surgery. Health personnel needs to address the experience and perception of pain and psychological struggles, and how it influences patients' everyday life including sleeping routines, work- and family life as well as to identify possible vulnerability for persistent postsurgical pain. Identifying and assessing the challenges enables personalized care and support, such as advice on pain management, cognitive support, guided rehabilitation, and coping strategies both pre-and post-surgery.

The Desired Oxford Knee Score Obtained Before Total Knee Arthroplasty is Predictive of the Postoperative Oxford Knee Score: A Prospective Study

BACKGROUND

The relationship between patient expectations and patient-reported outcome measures (PROMs) after total knee arthroplasty (TKA) is not well understood. The purpose of the study was to test the influence of desired knee function on postoperative perceived knee function 1 year after TKA.

METHODS

A total of 102 patients undergoing primary TKA were available for data analyses. Preoperatively, patients completed the Oxford Knee Score (OKS) twice, one representing preoperative function (preoperative OKS); the second representing desired function after TKA (desired OKS). Western Ontario and McMaster Universities Arthritis Index (WOMAC), University of California, Los Angeles (UCLA) Activity score, Hospital for Special Surgery Knee Replacement Expectations Survey (HSS-KRES), Patient Health Questionnaire-9, and EuroQol-visual analogue scales were obtained preoperatively. One year after surgery, all surveys besides the UCLA activity score and HSS-KRES were repeated. The associations between postoperative OKS and WOMAC versus desired OKS and HSS-KRES were assessed using multivariable linear regression models, wherein linear regression coefficients represent the additive effect on the mean postoperative PROM.

RESULTS

The desired OKS was independently associated with the postoperative OKS (linear regression coefficient = 0.43; P = .011), that is, each point increase in desired OKS yielded a 0.43 increase in postoperative OKS. The preoperative OKS showed no association with postoperative PROMs. Desired OKS was correlated with postoperative WOMAC (coefficient = -0.67; P = .014). The HSS-KRES was not associated with the postoperative OKS (coefficient = -0.005; P = .965) or WOMAC (coefficient = 0.18; P = .288).

CONCLUSION

In TKA patients, higher preoperative desired function predict greater postoperative PROMs. Effects of preoperative expectations on outcomes are independent of patient demographics or preoperative function.

Carpal Tunnel Syndrome and Ulnar Nerve Entrapment Are Associated with Impaired Psychological Health in Adults as Appraised by Their Increased Use of Psychotropic Medication

We aimed to study psychological health, as approximated by the use of psychotropic drugs, in a population diagnosed and surgically treated for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, also considering the demographic and socioeconomic factors of the individuals. Linking data from five large national registers, use of psychotropics (at least one dispensation during the first year after the surgery or the baseline date) was examined in around 5.8 million people 25–80 years old residing in Sweden 2010. Among these individuals, 9728 (0.17%), 890 (0.02%) and 149 (0.00%) were identified as diagnosed and surgically treated for CTS, UNE, or both, respectively. As much as 28%, 34% and 36% in each group, respectively, used psychotropic drugs, compared with 19% in the general population. Regression analyses showed a general higher risk for use of psychotropics related to these nerve compression disorders, to higher age, being a woman, and having low income or low occupational qualification level. Individuals born outside of Sweden had a lower risk. We conclude that surgically treated individuals with a nerve compression disorder have an increased risk of impaired psychological health. Caregivers should be aware of the risk and provide necessary attention.

Specific knowledge and resilience affect short-term outcome in patients following primary total hip arthroplasty

PURPOSE

The aim of the present study was to investigate the potential associations between specific knowledge, resilience and patient-reported outcome measures (PROMS) following primary total hip arthroplasty (THA).

METHODS

In a cross-sectional prospective study, consecutive patients following primary THA were included at a rehabilitation center. A novel knowledge score and the validated Connor Davidson Resilience Scale (CD-RISC) were utilized to assess patients' specific knowledge and resilience, respectively. Additionally, patients completed a qualitative questionnaire regarding the information they had received. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), as well as the University of California and Los Angeles Score (UCLA) served as primary outcome measures. Stepwise multiple regression analysis was performed to identify potential predictors of outcome.

RESULTS

A total of 103 patients at a mean age of 67.5 years (SD 10.5, 38-88) were included in the analysis at a median of 55.5 days (IQR 43-81) following primary THA. The mean knowledge and resilience scores were 3.8 (SD 1.6, 0-7) and 69.5 (SD 18.5, 0-100), respectively. Forty-seven percent of patients were afraid of harming their prosthesis and these patients had up to 59% worse WOMAC scores (p < 0.001). WOMAC scores on admission to rehabilitation were predicted by resilience and knowledge scores (R2 = 0.106, p = 0.036). UCLA scores at the time of admission were predicted by knowledge scores (R2 = 0.078, p = 0.007).

CONCLUSION

The present study demonstrated that patients with a feeling of uncertainty had an inferior short-term functional outcome following primary THA. Moreover, it could be shown that higher specific knowledge and resilience are associated with a better functional outcome according to validated PROMS. While these findings need to be prospectively validated in future studies, specific patient knowledge and resilience may have a direct impact on the outcome of primary THA.

Early post-operative oxford knee score and knee society score predict patient satisfaction 2 years after total knee arthroplasty

BACKGROUND

There is poor correlation between functional outcomes and patient satisfaction following total knee arthroplasty (TKA). We asked if early post-operative scores at 6 months or the pre- to post-operative change in scores are predictive of patient satisfaction 2 years after TKA.

METHODS

We conducted a retrospective review of prospectively collected registry data of 4359 TKAs performed at a single institution. At 6 months and 2 years, the Knee Society Score (KSS), Oxford Knee Score (OKS), and Short-Form 36 scores were assessed. A satisfaction questionnaire was also completed. Logistic regression was used to generate receiver-operating characteristic (ROC) curves to assess the ability of each scoring system in predicting satisfaction at 2 years.

RESULTS

At 2 years, 91.1% of patients were satisfied. For the absolute post-operative OKS at 6 months, an AUC of 0.762 (95% CI 0.736-0.788) and a threshold of ≤ 21.5 points (or ≥ 38.5 points on the new scale) were obtained. For the KSS knee score, an AUC of 0.704 (95% CI 0.674-0.734) and a threshold of ≥ 80.5 points were identified. The OKS performed significantly better than the KSS knee score (p = 0.03) and the other post-operative scores (p < 0.001). When analysing the change in scores pre-operatively to 6 months, the AUC was < 0.7 for all scales.

CONCLUSIONS

Early post-operative scores, specifically the OKS and KSS knee score, can predict patient satisfaction at 2 years after TKA with good accuracy. The threshold values offer surgeons an additional tool to identify patients at risk of dissatisfaction at 2 years, enabling them to intervene earlier to ensure good patient satisfaction.

LEVEL OF EVIDENCE

III, retrospective cohort study.