Major depression, generalized anxiety disorder, and panic disorder in patients scheduled for knee arthroplasty

Effect of Depression Interventions in Patients Undergoing Total Joint Arthroplasty Without a Formal Diagnosis of Depression: A Systematic Review

PURPOSE

Depression is a notable contributor to suboptimal outcomes after total joint arthroplasty (TJA). We conducted a systematic review of comparative studies to review the available evidence of interventions that affected depression scores and/or outcomes for patients undergoing TJA.

METHODS

EMBASE, Ovid MEDLINE, PubMed, and Scopus were reviewed systematically from inception until November 15, 2022. Studies that were relevant for this review included comparative studies between patients who received an intervention within 3 months before or after their primary total hip or knee arthroplasty procedure. The interventions included a wide range of modalities, which were grouped into psychotherapy, enhanced perioperative support, and pharmacotherapy. Other interventions included physiotherapy techniques with a psychological focus, art/music-based therapy, occupational therapy support, and educational interventions. Meta-analysis was conducted for psychotherapy and enhanced support.

RESULTS

The final systematic review consisted of 28 relevant studies, most of which were randomized controlled trials. A total of 3,702 patients, with a mean age of 66 years, were considered, of whom 59% were female. Most of the studies reported a notable reduction in depressive symptoms and/or scores based on the interventions being analyzed. At 3 months postoperatively, psychotherapy and enhanced support both resulted in markedly better depression and function scores compared with control subjects, with psychotherapy additionally improving pain scores.

CONCLUSIONS

Overall, a wide range of interventions aimed at psychological optimization of patients undergoing TJA can improve depressive symptoms, pain, and function, even in the absence of a formal diagnosis of depression. Specifically, cognitive-based psychotherapy and enhanced perioperative support had the best evidence. Routine pharmacotherapy plays a limited role, if any, in the care of TJA. Additional efforts to develop pragmatic, evidence-based, and reproducible interventions are warranted to continue to optimize outcomes in TJA patients.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Mental Health and Housing Status-Part Five of the Movement Is Life Special ONJ Series

Mental health and housing status have the potential to impact total joint arthroplasty (TJA) outcomes and are common TJA eligibility criteria that prevent patients from receiving surgery. Our aim was to formulate recommendations for how nurse navigators can assist patients with managing mental health and housing concerns. Through discussions with nurse navigators and a literature search across two databases, we gathered information regarding the optimization of mental health and housing status among TJA patients. We observed a lack of standardized protocols for addressing these concerns and literature supporting an increased focus on mental health and housing status, indicating the potential for greater nurse navigator involvement in developing and implementing protocols. We recommend nurse navigators use screening tools to identify mental health and housing concerns and offer the suggested resources to support patients in an effort to improve postoperative outcomes and decrease surgical risks.

Impact of Demographic Variables on Recovery After Total Hip Arthroplasty

BACKGROUND

Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA.

METHODS

There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations.

RESULTS

Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002).

CONCLUSIONS

Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.

Role of pre-operative counseling with NSQIP surgical risk calculator in the surgical patients

Introduction

Patient satisfaction is important tool to monitor health care performance and quality of health plans, emphasizing effective counseling and consent processes. The objective of the study is to assess patient satisfaction and anxiety with the use of NSQIP surgical risk calculator in comparison to standardized questionnaires.

Methodology

This is an interventional prospective randomized study. Difference in patient satisfaction is assessed by a 7-point Likert scale and anxiety assessment by 5-point Likert scale of Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire written in Nepalese. Satisfaction scores were compared using analysis of variance (ANOVA), or the Kruskal-Wallis test. P- value <0.05 was considered statistically significant.

Results

Satisfaction score regarding comfort during counseling and consent process was similar with and without use of NSQIP surgical risk calculator (83.3 % and 76.9 %, respectively). Satisfaction score regarding plan of anesthesia was 63.33 % with the use of NSQIP and 53.8 % without NSQIP tool. 30.76 % of patients with high school education developed negative feelings following counseling when NSQIP tool was not used (p value 0.002). NSQIP usage increased anxiety about anesthesia and surgery and led to higher continual thinking about the procedure.Duration of counseling was 12 min with NSQIP tool use in comparison to 9.67 min following conventional counseling (p value 0.047).

Conclusion

NSQIP surgical risk calculator is a reliable tool that can be used alongside conventional methods during preoperative period for decision-making and counseling with similar satisfaction scores but a higher incidence of anxiety and continual thinking about procedures.

Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment

The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.

Relationships Between Preoperative Mental Health and Improvements in Patient-Reported Outcomes After Total Hip and Knee Arthroplasty

BACKGROUND

Poor preoperative mental health has been associated with worse outcomes after total hip (THA) and total knee arthroplasty (TKA). To fully understand these relationships, we assessed post-THA and post-TKA improvements in patient-reported mental and joint health by preoperative mental health groups.

METHODS

Elective cases (367 THA, 462 TKA) were subgrouped by low (<25th percentile), middle (25th-74th), and high (≥75th) preoperative mental health, using Veterans RAND 12-Item Health Survey Mental Component Summary (MCS) scores. In each subgroup, we assessed the relationship between preoperative MCS and 1-year postoperative change in mental and joint health. Pairwise comparisons and multivariable regression models were applied for THA and TKA separately.

RESULTS

Median postoperative mental health change was +14.0 points for the low-MCS THA group, +11.1 low-TKA, +2.0 middle-THA and TKA, -4.0 high-THA, and -4.9 high-TKA (between-group differences P < .001). All MCS groups had improved median joint health scores, without significant between-group differences. Preoperative mental health was negatively associated with mental health improvements in all groups (B = -0.94 - -0.68, P < .001-P = .01) but with improvements in joint health only in the low-THA group (B = -0.74, P = .02). Improvements in mental and joint health were positively associated for low and middle (B = 0.61-0.87, P < .001), but not for high-MCS groups, with this relationship differing for the low versus high group.

CONCLUSION

Patients who have low preoperative mental health experienced greater postoperative mental health improvement and similar joint health improvement compared to patients who have high preoperative mental health. Findings can guide subgroup-targeted surgical decision-making and preoperative counseling.

Preoperative anxiety during COVID-19 pandemic: A single-center observational study and comparison with a historical cohort

Background

Preoperative anxiety is a common sensation experienced by patients undergoing surgical interventions. It can influence intraoperative and postoperative management through the activation of the neuroendocrine system, leading to tachycardia, hypertension, pulmonary complications, higher consumption of anesthetic drugs, and increased postoperative pain. Our aim was to investigate the level of preoperative anxiety during the COVID-19 pandemic; we also compared it to the preoperative anxiety of a historical cohort before the outbreak.

Methods

This is a single-center observational study. We enrolled 314 patients during the pandemic from May 2021 to November 2021, and our historical cohort consisted of 122 patients enrolled from July 2015 to May 2016 in the university hospital "Federico II" of Naples. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and the State-Trait Anxiety Inventory (STAI) were used to evaluate preoperative anxiety. In particular, APAIS measures preoperative anxiety and the need for information, and STAI assesses state and trait anxiety through STAI-Y1 and STAI-Y2, respectively. We analyzed APAIS and STAI scores in our population stratified on the basis of age, gender, marital status, previous surgical experiences, and type of surgery, and we compared them to our historical cohort. Statistical analysis was performed through a t-test and ANOVA for parametric data, and the Mann-Whitney and Kruskal-Wallis tests for non-parametric data. Linear regression was used to investigate the correlation between demographic data and the scores of STAI and APAIS in both groups.

Results

Our results showed that state and preoperative anxiety remained stable, whereas trait anxiety increased in all the subgroups analyzed.

Discussion

Even if state anxiety is considered a variable characteristic of the emotional sphere and trait anxiety a stable element, our findings suggested that COVID-19 deeply influenced trait anxiety, thus altering the patients' psychological foundations.

Personality, Preoperative Anxiety, and Postoperative Outcomes: A Review

Research has shown that personality is associated with anxiety levels in the general population. However, little is known about the relationship between personality and preoperative anxiety and the subsequent health outcomes in patients undergoing surgery. Therefore, this review aimed to identify studies that explored the relationship between personality traits and preoperative anxiety, as well as their association with postoperative outcomes. Existing literature shows that anxiety may play an intermediary role in the relationship between personality and postoperative outcomes. Severe anxiety may partially explain the adverse effects of certain personality traits, such as neuroticism, on postoperative outcomes. However, the relationship between personality traits, preoperative anxiety, and postoperative outcomes remains unclear. Interventions such as clinical evaluation, preoperative counseling, and management strategies can be of great value in identifying and resolving patients' anxiety and negative emotions to improve postoperative outcomes.

The Outcome of Total Knee Arthroplasty for Patients with Psychiatric Disorders: A Single-Center Retrospective Study

Background and Objectives: For some years, psychiatric illness has been a major factor in evaluating the results of total knee arthroplasty. As with other patient-related items, patients diagnosed with mental illness have higher costs of medical treatment, longer recovery, and longer hospital stays. The aim of this paper is to evaluate the role of mental diseases on the surgical outcome compared with the normal population. Materials and Methods: At our hospital, we undertook a retrospective study between June 2020 and January 2022. The experimental group consisted of patients with mental diseases including schizophrenia, bipolar disease, depression, substance uses, or other psychiatric disorders. The control group consisted of patients who underwent total knee arthroplasty and did not have a mental disease. Postoperative complications and length of stay were also recorded during the study. We used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Knee Society Score (KSS) as outcome measures. Results: Between June 2020 and January 2022, a total of 634 patients underwent total knee arthroplasty in our clinic, of which 239 had a mental disease. The majority of patients were female (61%), and the average length of stay was significantly longer for patients with mental illness (6.8 vs. 2.8 days). Preoperative WOMAC and KS function scores demonstrated statistically significant differences between groups (67.83 ± 17.8 vs. 62.75 ± 15.7 and 29.31 ± 19.8 vs. 34.98 ± 21.3). KS knee score did not show any significant differences preoperatively. All postoperative functional scores showed significantly better results for the control group compared to the mental illness group. Conclusions: Mental illness appears to be linked with lower TKA scores before and after the surgical procedure.

Greater Prevalence of Mental Health Conditions in Septic Revision Total Knee Arthroplasty: A Call to Action

The purpose of this study was to compare the prevalence of mental health conditions among patients undergoing (1) primary total knee arthroplasty (pTKA), (2) septic revision total knee arthroplasty (rTKA), and (3) aseptic revision total knee arthroplasty (TKA). The State Inpatient Databases were queried for all TKAs from 2005 to 2014 yielding 563,144 patients. Patients were separated into the following cohorts: primary, septic revision, and aseptic revision. Diagnoses of any mental health condition and the following specific conditions were compared between the three cohorts: schizophrenia/delusion, bipolar disorder, depression/mood disorder, personality disorder, anxiety/somatic/dissociative disorder, eating disorders, attention deficit hyperactivity disorder/conduct/impulse control, alcohol abuse, and drug abuse. Throughout the study period, an increase in the prevalence of mental health conditions was observed in septic and aseptic revision patients. Overall, there was a significantly higher prevalence of mental health conditions in the septic revision cohort (22.7%) compared with the primary (17.8%, p < 0.001) and aseptic revision (20.0%, p < 0.001) cohorts. Specifically, septic revision TKA patients had a higher prevalence of depression (p < 0.001), alcohol abuse (p < 0.001), drug abuse (p < 0.001), schizophrenia (p = 0.0007), and bipolar disorder (p < 0.001), compared with primary TKA patients. Additionally, there was a significantly higher prevalence of depression (p < 0.001), alcohol abuse (p < 0.001), and drug abuse (p < 0.001) among septic revision patients compared with aseptic revision patients. Mental health conditions were significantly higher among septic revision patients. Alcohol and drug abuse were approximately twice as prevalent in septic revision patients compared with primary and aseptic revision patients. These findings should serve as a call to action for mental health support for patients suffering from PJI.

Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

To date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA.

METHODS

We systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty.

RESULTS

We included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types.

CONCLUSION

Based on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Anxiety and Depression Impact on Inhospital Complications and Outcomes After Total Knee and Hip Arthroplasty: A Propensity Score-Weighted Retrospective Analysis

INTRODUCTION

The purpose of this study was to assess the impact of anxiety and depression on immediate inhospital outcomes and complications after total joint arthroplasty of the hip (total hip arthroplasty [THA]) and knee (total knee arthroplasty [TKA]) using a large national registry.

METHODS

Data from the National Inpatient Sample was used to identify all patients undergoing TKA and THA between 2006 and 2015. Patients were divided in four groups based on a concomitant diagnosis of depression, anxiety, depression plus anxiety, and neither depression nor anxiety (control group). Propensity score analysis was performed to determine whether these psychiatric comorbidities were risk factors for inhospital economic, disposition, and complication outcomes.

RESULTS

A total of 5,901,057 TKAs and 2,838,742 THAs were performed in our study period. The relative percentage of patients with anxiety and depression undergoing these procedures markedly increased over time. All three psychiatric comorbidity groups were markedly associated with an increased risk of postoperative anemia and were markedly associated with other inhospital complications compared with the control group. Notable associations were also found between the study groups and total charges, length of stay, and disposition.

DISCUSSION

Anxiety and depression are major risk factors for inhospital complications and are markedly associated with economic and disposition outcomes after TKA and THA. The relative proportion of patients with anxiety and depression undergoing these procedures is rapidly increasing. It is critical for clinicians to remain aware of these risk factors, and attention should be directed on the development of standardized perioperative optimization protocols and medication management for these patients.

LEVEL OF EVIDENCE

Level III, retrospective study.

The Effects of Depression and Anxiety on 90-day Readmission Rates After Total Hip and Knee Arthroplasty

Background

Patients undergoing total joint arthroplasty have higher rates of anxiety, depression or anxiety and depression than the general population and higher costs of care, which lead to higher levels of postoperative dissatisfaction and readmission rates. We evaluated the readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression, or both.

Methods

Our hospital's prospectively collected data from Michigan's statewide total joint database were reviewed from 2013 to 2018. Rates of anxiety, depression or anxiety and depression were determined based on preoperative anxiolytic or antidepressant medications using National Drug Codes.

Results

A total of 4107 cases were included. Of which 4.28% had a readmission within the 90-day global period, and 12% had a history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (P = .017). When comparing total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients taking anxiolytic medication and undergoing TKA were 120% more likely to undergo readmission within 90 days (P = .021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (P = .991). For THA, neither diagnosis appeared a risk factor for readmission (P = .852).

Conclusions

Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90 days compared with patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. Patients undergoing THA on the other hand did not appear to share this risk profile.

Association of Depression and Anxiety With Expectations and Satisfaction in Foot and Ankle Surgery

INTRODUCTION

Mental health diagnoses involving depression or anxiety are common and can have a dramatic effect on patients with musculoskeletal pathologies. In orthopaedics, depression/anxiety (D/A) is associated with worse postoperative patient-reported outcomes. However, few studies have assessed the effect of D/A on expectations and satisfaction in foot and ankle patients.

METHODS

Adult patients undergoing elective foot and ankle surgery were prospectively enrolled. Preoperatively, patients completed the eight-item Patient Health Questionnaire Depression Scale, Generalized Anxiety Disorder Screener-7, Foot and Ankle Outcome Score (FAOS), and Expectations Survey. At 2 years postoperatively, surveys including satisfaction, improvement, and fulfillment of expectations were administered. Fulfillment of expectations (fulfillment proportion) and FAOS scores were compared between patients with D/A and non-D/A patients.

RESULTS

Of 340 patients initially surveyed, 271 (80%) completed 2-year postoperative expectations surveys. One in five patients had D/A symptoms. Preoperatively, D/A patients had greater expectations of surgery (P = 0.015). After adjusting for measured confounders, the average 2-year postoperative fulfillment proportion was not significantly lower among D/A compared with non-D/A (0.86 versus 0.78, P = 0.2284). Although FAOS scores improved postoperatively for both groups, D/A patients had significantly lower preoperative and postoperative FAOS scores for domains of symptoms, activity, and quality of life (P < 0.05 for all). D/A patients reported less improvement (P = 0.036) and less satisfaction (P = 0.005) and were less likely willing to recommend surgery to others (P = 0.011).

DISCUSSION

Patients with D/A symptoms had higher preoperative expectations of surgery. Although D/A patients had statistically similar rates of fulfillment of expectations compared with non-D/A patients, they had markedly lower FAOS scores for domains of symptoms, activity, and quality of life. D/A patients also perceived less improvement and were more often dissatisfied with their outcomes. These findings should not dissuade providers from treating these patients surgically but rather emphasize the importance of careful patient selection and preoperative expectation management.

LEVEL OF EVIDENCE

Level III; retrospective review of prospective cohort study.

Generalized Anxiety Disorder: A Modifiable Risk Factor for Pain Catastrophizing After Total Joint Arthroplasty

BACKGROUND

Patients with mood disorders undergoing total joint arthroplasty (TJA) are at increased risk for poor outcomes. This study seeks to examine the effect of anxiety disorders on pain following TJA and evaluate if anxiety disorders are a modifiable risk factor.

METHODS

Between March 2019 and July 2020, 319 TJA patients had preoperative anxiety screening using the Generalized Anxiety Disorder 2-item screening tool (GAD-2) and 6-week postoperative Pain Catastrophizing Scale scores. Patients were organized into 4 cohorts based on preoperative selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) use and GAD-2 scores: Group 1: no SSRI/SNRI use and GAD-2 score <3 (control patients); Group 2: SSRI/SNRI use and GAD-2 score <3 (appropriately treated GAD patients); Group 3: no SSRI/SNRI use and GAD-2 score ≥3 (untreated GAD patients); and Group 4: SSRI/SNRI use and GAD-2 score ≥3 (poorly treated GAD patients). The cohorts underwent multivariate linear regression analysis and equivalence testing.

RESULTS

Patients with preoperative GAD-2 scores ≥3 had worse postoperative pain with significantly higher average 6-week postoperative Pain Catastrophizing Scale score than patients with GAD-2 scores <3 (9.90 vs 5.19, P < .001). Patients with appropriately treated GAD and the control group had statistically equivalent postoperative pain, while patients with poorly treated or untreated GAD had worse postoperative pain.

CONCLUSION

Preoperative GAD is a risk factor for poor postoperative pain control but is a modifiable risk factor when patients are appropriately treated. Screening for preoperative GAD with GAD-2 and referral for treatment may improve patient outcomes and reduce opioid consumption following TJA.

The Impact of Preoperative Mental Health and Depression on Outcomes After Total Ankle Arthroplasty

BACKGROUND

Preoperative mental health and depression have been shown to negatively impact patient-reported outcome measures after a broad array of orthopaedic procedures including total ankle arthroplasty. The hypothesis for this study was that decreased Short Form (SF)-36 Mental Component Summary (MCS) scores will modulate the impact of depression on patient-reported outcome measures after total ankle arthroplasty.

METHODS

All patients undergoing primary total ankle arthroplasty between January 2007 and December 2016 who were enrolled into a prospective outcomes study and who had at least 1-year minimum study follow-up were retrospectively reviewed. Patients were separated into 4 groups based on the presence or absence of an SF-36 MCS score of <35 points and diagnosis of depression. SF-36 Physical Component Summary (PCS) and MCS scores, Short Musculoskeletal Function Assessment (SMFA) function and bother components, and visual analog scale (VAS) pain were collected preoperatively and in the 1 to 2-year follow-up. The Wilcoxon rank sum was used to assess differences in outcomes by depression and low preoperative MCS scores. Multivariable models were then constructed to evaluate between-group differences in change scores according to preoperative SF-36 MCS scores and a diagnosis of depression, with adjustment for baseline patient and treatment characteristics.

RESULTS

Patients with depression and those with low preoperative MCS scores had significantly worse final outcome scores along with reduced improvement in SF-36 PCS and VAS pain scores compared with patients without these risk factors. Among patients with depression, low preoperative MCS scores helped to differentiate patients with poor final outcome scores. Similarly, in patients with low preoperative MCS scores, depression helped to differentiate patients with poor final outcome scores.

CONCLUSIONS

Although patients achieved significant improvements in functional outcomes regardless of cohort, decreased preoperative mental health modulated the impact of depression on outcomes. Patients with diminished preoperative mental health and depression are at an increased risk for sustaining smaller improvements in outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Depression Treatment Is Not Associated With Improved Patient-Reported Outcomes Following Total Joint Arthroplasty

BACKGROUND

The objective of this study was to investigate if there were differences in disease-specific, overall health, and activity outcomes after total joint arthroplasty (TJA) between treated and untreated depressed patients.

METHODS

Patients who underwent primary, elective, unilateral TJA were divided into 3 groups based on self-reported history of depression and treatment at the time of surgery: 1) patients without depression, 2) patients with treated depression, and 3) patients with untreated depression. The primary outcomes were the differences in SF-12 PCS, SF-12 MCS, WOMAC, and UCLA activity rating scale up to 12 months postoperatively. A secondary outcome was the effect of depression treatment on patients' perception of experiencing limitation in their activities due to depression. Univariate and mixed-effects model analyses were performed to control for potential confounding factors.

RESULTS

The prevalence of depression was 189/749 (25%). Compared to patients with treated depression, untreated patients had lower baseline SF-12 MCS (P < .001) and were more likely to have Medicaid insurance (P < .001). After controlling for potential confounding factors, there were no differences in either the absolute scores or net changes in any of the assessed outcomes at 12 months postoperatively among depressed patients regardless of treatment (P > .05). In addition, depression treatment did not affect patients' perception of activity limitation (P = .412).

CONCLUSION

Although it is clear that depression adversely impacts patient outcomes in primary TJA, treatment does not appear to mitigate this negative effect. Depression treatment does not necessarily imply resolution of depressive symptoms. Future studies should explore alternative interventions to reduce the health-related consequences of depression to optimize the outcomes of TJA.

Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

BACKGROUND

Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs.

METHODS

This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015).

RESULTS

The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m² or 35-40 kg/m² with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93).

CONCLUSION

In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.

The Effect of Depression on Patient-Reported Outcomes After Total Joint Arthroplasty Is Modulated by Baseline Mental Health: A Registry Study

BACKGROUND

Depression and poor mental health are known to be negative predictors of patient-reported outcomes after total joint arthroplasty. Although previous studies have examined these risk factors in isolation to each other, they are, in reality, closely related, and yet each represents a different aspect of one's psychological well-being. The objective of this study was to investigate the association between depression and patient-reported outcomes, taking into account patients' baseline mental health.

METHODS

Our prospective, institutional joint registry was queried for patients who had undergone primary elective total joint arthroplasty and had a minimum follow-up of 1 year. Baseline mental health was measured by the Short Form-12 Mental Component Summary (SF-12 MCS). Four cohorts were analyzed on the basis of the presence or absence of depression and patients' SF-12 MCS scores at the time of the surgical procedure, which were categorized as either poor or good on the basis of previously defined cutoffs. The primary outcomes were the net changes in SF-12 MCS, SF-12 Physical Component Summary (PCS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at 4 and 12 months postoperatively. Univariate and mixed-effects model analyses were performed to control for potential confounding factors.

RESULTS

Patients with depression but good baseline mental health achieved gains in patient-reported outcomes that were comparable with those of normal controls (p > 0.05). Patients with poor baseline mental health achieved significant gains in all patient-reported outcomes, but the changes were largest for those without depression (p < 0.05). Only patients with depression and poor baseline mental health did not cross the threshold for good mental health at the time of the latest follow-up despite achieving similar gains in physical function compared with their counterparts who did not have depression.

CONCLUSIONS

The effect of depression on patient-reported outcomes is more complex but less pessimistic than previously thought. Patients with depression undergoing total joint arthroplasty may have significant improvements in their patient-reported outcomes, but the net gains are modulated by their mental health at the time of the surgical procedure. Preoperative screening of patients with depression using the SF-12 MCS may help to identify those who are at risk for attaining suboptimal patient-reported outcomes and may benefit from counseling or psychiatric referral for optimization before undergoing a surgical procedure.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Inpatient Use of Selective Serotonin Reuptake Inhibitors Is Associated With a Reduced Risk of THA and TKA Revision

BACKGROUND

Depression is common in the general population, and so it is likewise common among patients undergoing THA and TKA. Depression is associated with lower perioperative patient-reported outcomes and an increased risk of postoperative complications. Antidepressants are effective in managing symptoms of depression and may potentially contribute to better functional status and better clinical outcomes after THA and TKA.

QUESTIONS/PURPOSES

We examined (1) whether perioperative depression is associated with all-cause revisions, revisions for aseptic loosening, revisions without infection, and periprosthetic joint infections (PJIs) in patients undergoing THA and TKA; and (2) whether perioperative antidepressant use reduces the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs in patients undergoing THA and TKA.

METHODS

This was a retrospective study of adult patients (≥ 18 years) who underwent 20,112 primary and revision THAs and TKAs from January 1, 2002, through December 31, 2009, at a large US tertiary care hospital. Data on patient and surgery characteristics and outcomes (dates and types of revisions, death) were ascertained through the institutional joint registry. Perioperative antidepressant use was assessed by searching the daily medication administration records beginning at admission and ending at discharge. A diagnosis of depression was present in 4466 (22%), and antidepressants were administered at the time of 5077 (25%) surgical procedures. Multivariable Cox proportional hazard models were used to estimate associations between antidepressant use and the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs.

RESULTS

Depression was associated with an increased risk of all-cause revisions (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.42-2.02; p < 0.001) and PJIs (HR, 2.23; 95% CI, 1.53-3.17; p < 0.001). Overall, perioperative antidepressant use was not associated with the risk of revision or PJI, but selective serotonin reuptake inhibitor (SSRI) users had a lower risk of all-cause revisions (HR, 0.77; 95% CI, 0.61-0.96; p = 0.001) and aseptic revisions (HR, 0.72; 95% CI, 0.56-0.93; p = 0.013).

CONCLUSIONS

The presence of a depression diagnosis confers an increased risk of revision and PJI among patients undergoing THA and TKA, yet the risk is lower within the subset of patients who received SSRIs during the perioperative period. Future longitudinal studies with detailed antidepressant medication histories are warranted to better understand the potential biologic effects of SSRI on the risk of revision in patients undergoing THA and TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Changes in Anxiety and Depression Are Mediated by Changes in Pain Severity in Patients Undergoing Lower-Extremity Total Joint Arthroplasty

BACKGROUND

Depression and anxiety are common comorbidities in chronic pain including osteoarthritis patients undergoing total joint arthroplasty (TJA). What is not clear is whether psychiatric comorbidity precedes the manifestation of painful states or represents a reaction to living with chronic pain and associated functional impairment. The objective of this research was to explore whether decreases in depressive and anxiety symptoms after lower-extremity TJA could be due to postsurgical reductions in pain.

METHODS

We conducted a secondary analysis of data from 1448 TJA patients enrolled in the Analgesics Outcome Study. Patients completed measures of pain intensity, functional status, and depressive and anxiety symptoms preoperatively and at 3 and 6 months postoperatively. Data were analyzed using a structural equation modeling approach.

RESULTS

We found that improvement in pain and physical function from baseline to 6 months postoperatively was associated with improvement in depression and anxiety symptoms. We also found that a change in overall body pain at 3 months after surgery significantly mediated changes in both the depression and anxiety scores at 6 months after surgery even when controlling for age, sex, baseline body pain, education, opioid use, and type of surgery.

CONCLUSIONS

Presurgical affective symptoms not only have an effect on change in postsurgical pain, whereby lower preoperative scores on depression and anxiety were associated with lower postsurgical pain, but also postsurgical decreases in pain were associated with lower levels of depression and anxiety after surgery. Taking these points into consideration may prove useful in working toward better outcomes for TJA.

The presence and influence of mild depressive symptoms on post-operative pain perception following primary total knee arthroplasty

PURPOSE

To evaluate the influence of mild depression on pain perception after total knee arthroplasty (TKA).

METHODS

Hamilton depression (HDRS) and numeric rating (NRS) scales were used to evaluate depression severity and pain perception at various intervals surrounding TKA. The Hospital for Special Surgery (HSS) knee and pain scores (NRS) in patients with signs of mild depression (HDRS < 20 points) were compared to a control group of patients with no signs of depression (HDRS < 8 points).

RESULTS

Prior to surgery, there were no statistical differences in pain perception (NRS) or individual components of HSS knee score including range of motion, pain, and function between patients with mild depression compared to controls. However, following surgery, patients with signs of mild depression were more likely to report more pain (p < 0.001) and have lower HSS scores even at 1 year post-operatively (p < 0.001).

CONCLUSIONS

A significant number of patients in this series undergoing routine primary TKA had signs of subclinical depression. These patients are more likely to report increased pain even at 1 year following surgery compared to patients without signs of depression preoperatively. Psychometric evaluation prior to surgery can help identify the at-risk patient and allow for proper management of patient expectations, thus improving clinical results and patients' satisfaction after TKA.

LEVEL OF EVIDENCE

Prospective comparative study, II.

Restoring integrity--A grounded theory of coping with a fast track surgery programme

AIMS AND OBJECTIVES

The aim of this study was to generate a theory conceptualizing and explaining behavioural processes involved in coping in order to identify the predominant coping types and coping type-specific features.

BACKGROUND

Patients undergoing fast track procedures do not experience a higher risk of complications, readmission, or mortality. However, such programmes presuppose an increasing degree of patient involvement, placing high educational, physical, and mental demands on the patients. There is a lack of knowledge about how patients understand and cope with fast track programmes.

DESIGN

The study design used classical grounded theory.

METHODS

The study used a multimodal approach with qualitative and quantitative data sets from 14 patients.

RESULTS

Four predominant types of coping, with distinct physiological, cognitive, affective, and psychosocial features, existed among patients going through a fast track total hip replacement programme. These patients' main concern was to restore their physical and psychosocial integrity, which had been compromised by reduced function and mobility in daily life. To restore integrity they economized their mental resources, while striving to fulfil the expectations of the fast track programme. This goal was achieved by being mentally proactive and physically active. Three out of the four predominant types of coping matched the expectations expressed in the fast track programme. The non-matching behaviour was seen among the most nervous patients, who claimed the right to diverge from the programme.

CONCLUSION

In theory, four predominant types of coping with distinct physiological, cognitive, affective, and psychosocial features occur among patients going through a fast track total hip arthroplasty programme.

What is the role of mental health in primary total knee arthroplasty?

BACKGROUND

Psychological distress has been associated with inferior scores for pain after total knee arthroplasty (TKA). However, its relationships with scores and arthrofibrosis after TKA remain unclear.

QUESTION/PURPOSES

The objectives of this study were (1) to assess patient-reported outcomes (PROs), including Knee Society (KS) scores, of those patients who developed arthrofibrosis and underwent manipulation and compare them with a control group; and (2) in patients with arthrofibrosis who underwent manipulation, to determine PROs and KS scores of those with psychological distress and those without it.

METHODS

During a 17-year period (August 1992 to October 2009), a total of 1952 TKAs were performed and included in our prospectively collected joint registry database; 1248 procedures had a postoperative followup of at least 2 years (mean, 5 years; range, 2-16 years). Among them, 57 knees (53 patients) developed arthrofibrosis and underwent manipulation under anesthesia after the index procedure. This group was compared with a matched group (by age, sex, race, and ethnicity) of 63 knees (58 patients) without arthrofibrosis. Demographics, preoperative and postoperative Quality of Well-Being scale (QWB-7), SF-36, WOMAC, and The KS knee and function scores were prospectively collected and retrospectively analyzed. Patients with <52 points on the SF-36 Mental Component Summary subscale were considered in psychological distress for all comparisons. Active knee flexion and KS range of motion (ROM) were used as objective motion measures. Minimum followup was 2 years (mean, 5 years; range, 2-16 years).

RESULTS

Patients who developed arthrofibrosis had worse KS function scores before TKA than did patients in the nonarthrofibrosis control group (mean 27, SD 20.5 versus 37, SD 19.3; p=0.006). Patients with arthrofibrosis and psychological distress, before TKA and when compared with patients with arthrofibrosis but without distress, had worse QWB-7 (0.490 versus 0.547; p<0.001) and worse WOMAC stiffness (4.92, versus 3.22; p=0.005), respectively. Postoperatively, patients with arthrofibrosis and distress also had worse QWB-7 (0.537 versus 0.627; p=0.002).

CONCLUSIONS

Patients with arthrofibrosis and psychological distress perceived themselves preoperatively as having worse knee and overall health status than those with arthrofibrosis but without distress. In view of this, expectations after TKA should be particularly addressed in those patients with poor function and psychological distress. Further investigations, making use of tools specifically designed to ascertain depression, are warranted.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Integration of animal behaviors under stresses with different time courses

We used animal models of "forced swim stress" and "chronic unpredictable stress", and tried to reveal whether a passive coping style of high flotation behavior in forced swim stress predicts anhedonia behavior after chronic unpredictable stress, and whether the dopamine system regulates floating and anhedonia behaviors. Our results confirmed that depression-prone rats use "floating behavior" as a coping strategy in forced swim stress and more readily suffer from anhedonia during chronic unpredictable stress. Intraperitoneal injection or nucleus accumbens microinjection of the dopamine 2/3 receptor subtype agonist ropinirole reduced floating behaviors in depression-prone animals, but increased sucrose preference in rats showing anhedonia. These data indicate that floating behavior is a defensive mode that is preferred by susceptible individuals under conditions of acute stress. Simultaneously, these animals more readily experienced anhedonia under long-term stress; that is, they were more readily affected by depression. Our results suggest that dopamine 2/3 receptor subtypes in the nucleus accumbens play an important role in floating behaviors and anhedonia.

Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study

The purpose of this study was to assess the incidence of the diagnosis of depression and determine the impact of this diagnosis on early postoperative outcomes following total joint arthroplasty (TJA). Multivariate analysis of the Nationwide Inpatient Sample database was used to compare the association of depression with inhospital morbidity, mortality, length of stay, and hospital charges following TJA. The rate of diagnosis of depression in the arthroplasty population was 10.0%. Patients with depression were significantly more likely to be white, female, and have Medicaid as a primary payer (all P<0.05). Depression was associated with a greater risk of post-operative psychosis (OR = 1.74), anemia (OR = 1.14), infection (OR = 1.33), and pulmonary embolism (OR 1.20), and a lower risk of cardiac (OR = 0.93) and gastrointestinal complications (OR = 0.80). Depression was not associated with in-hospital mortality. Depression appears to impact early postoperative morbidity after TJA, a finding which is important for patient counseling and risk adjustment.

The unhappy total knee arthroplasty (TKA) patient: higher WOMAC and lower KSS in depressed patients prior and after TKA

PURPOSE

Patient-based and psychological factors do influence outcome in patients undergoing total knee arthroplasty (TKA). The purpose was to investigate if preoperative psychological factors influence the subjective and objective outcomes 6 weeks, 4 months and 1 year after TKA. Our hypothesis was that there is a significant influence of psychological factors on clinical outcome scores before and after TKA.

METHODS

A prospective, longitudinal, single-cohort study investigating the correlation of depression, control beliefs, anxiety and a variety of other psychological factors with outcomes of patients undergoing TKA was performed. A total of 104 consecutive patients were investigated preoperatively using the Beck`s depression inventory, the State-Trait Anxiety Index, the questionnaire for assessment of control beliefs and the SCL-90R inventory. The Knee Society Clinical Rating System (KSS) and the WOMAC were used. Analysis of TKA position was performed on radiographs according to Ewald et al. Correlation of psychological variables with outcomes was performed (p < .05).

RESULTS

Self-efficacy did not influence clinical scores. More depressed patients showed higher pre- and postoperative WOMAC scores, but no difference in amelioration. KSS scores were not influenced. Patients with higher State and Trait Anxiety Indexes had higher WOMAC and lower KSS scores before and after the operation, but most significant correlations were <0.3. Several SCL-90 dimensions had significant correlations with pre- and postoperative clinical scores, but not with their amelioration. The SCL-90 subscore for somatization and the overall SCL-90 significantly correlated with the WOMAC, KSS before and after TKA.

CONCLUSIONS

Depression, anxiety, a tendency to somatize and psychological distress were identified as significant predictors for poorer clinical outcomes before and/or after TKA. Standardized preoperative screening and subsequent treatment should become part of the preoperative work-up in orthopaedic practice.

LEVEL OF EVIDENCE

Prognostic prospective, Level I.

The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair

BACKGROUND

Psychological status may be an important predictor of outcome and patient satisfaction after treatment for rotator cuff disease. Few prior studies have considered these factors. The objective of the study was to investigate the prevalence of psychological distress and its effect on self-assessed pain, disability, and health-related quality of life in patients scheduled for rotator cuff repair.

MATERIALS AND METHODS

We assessed 107 consecutive patients preoperatively using the Hospital Anxiety and Depression Scale (HADS); visual analog scale pain score; American Shoulder and Elbow Surgeons (ASES) scale; Korean Shoulder Scale (KSS); and World Health Organization Quality of Life Scale, Abbreviated Version (WHOQOL-BREF). Preoperative demographic, clinical, and radiologic parameters were also evaluated.

RESULTS

Of the patients, 28 (26.2%) had depression and 25 (23.4%) had anxiety. The HADS depression score was positively correlated with the visual analog scale pain score (P = .048) and negatively correlated with the ASES, KSS, and WHOQOL-BREF scores (P = .005, P = .004, and P < .0001, respectively). The HADS anxiety score was negatively correlated with the ASES, KSS, and WHOQOL-BREF scores (P = .034, P = .037, and P < .0001, respectively). On multivariate analysis with a linear regression model, the HADS depression score was an independent predictor of ASES, KSS, and WHOQOL-BREF scores (P = .02, P = .005, and P = .001, respectively).

CONCLUSION

Depression and anxiety had a negative impact on self-assessed outcome measurements in patients scheduled for rotator cuff repair. Depression was a strong predictor of functional disability and health-related quality of life. Our results suggest that preoperative psychological status may influence postoperative outcome after rotator cuff repair and thus is an essential part of preoperative assessment.