Outcomes of total joint arthroplasty in patients with depression: A systematic review

Association Between Pharmacologic Treatment of Depression and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty

BACKGROUND

Depression is associated with inferior outcomes following hip or knee arthroplasty, though it remains unclear if this relationship is modifiable. This study examined the association between pharmacologic treatment of depression and patient-reported outcomes.

METHODS

This retrospective cohort study of 1,651 total hip arthroplasty (THA) and 1,792 total knee arthroplasty (TKA) procedures between October 2012 and June 2019 used institutional registry data linked to nationwide pharmaceutical claims. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) global score, with pain and function sub-scales assessed as secondary outcomes. The TKA and THA patients were analyzed separately via mixed-effect linear regression to compare patients who had depression treated with antidepressants (TKA, n = 210; THA, n = 150) to those who had untreated depression (TKA, n = 43; THA; n = 50), and those who did not have depression (TKA, n = 1,539; THA, n = 1,451).

RESULTS

Among patients who had depression, not receiving preoperative antidepressant therapy was associated with smaller improvements in WOMAC global scores (TKA, adjusted mean difference [MD]: -13.1 points, 95% CI [confidence interval]: -21.4 to -4.8; THA, MD: -8.5 points, 95% CI: -15.7 to -1.2) at two years after surgery, but not at one year (TKA, MD: -5.4 points, 95% CI: -12.9 to 2.1; THA, MD: -6.3 points, 95% CI: -12.9 to 0.3). Those who did not have depression had similar improvements in WOMAC global scores to those who had treated depression at both one (TKA, MD: 0.8 points, 95% CI: -2.7 to 4.4; THA, MD: 1.8 points, 95% CI: -1.8 to 5.4) and two years (TKA, MD: -1.1 points, 95% CI: -4.9 to 2.7; THA, MD: -1.6 points, 95% CI: -5.6 to 2.3). The findings were consistent with secondary outcomes.

CONCLUSION

Among patients who have depression, antidepressant therapy before TKA or THA is associated with improved outcomes. Additional studies are needed to establish the impact of interventions to address untreated depression before surgery.

Preoperative Symptoms of Depression are Associated With Worse Capability 6-weeks and 6-months After Total Hip Arthroplasty for Osteoarthritis

BACKGROUND

Symptoms of depression have been associated with greater incapability following total hip arthroplasty (THA). A brief, 2-question, measure of symptoms of depression - the Patient Health Questionnaire-2 (PHQ-2) - may be sufficient to measure associations with the magnitude of incapability during recovery from THA. This study investigated whether preoperative symptoms of depression (measured with the PHQ-2) correlated with levels of incapability 6 weeks and 6 months after THA, accounting for demographic and clinical factors.

METHODS

We performed a prospective cohort study across 5 centers and recruited 101 patients undergoing THA, of whom 90 (89%) completed follow-up. Patients completed demographics, a preoperative 2-item (PHQ-2) measure of symptoms of depression, and the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) at 6-weeks and 6-months postoperatively. Negative binomial regression models determined factors associated with HOOS JR at 6 weeks and 6 months, accounting for potential confounders.

RESULTS

Accounting for potential confounding factors, we found that higher preoperative PHQ-2 scores (reflecting greater symptoms of depression) were associated with lower HOOS JR scores (reflecting a greater level of hip disability) at both 6 weeks (regression coefficient = -0.67, P < .001) and 6 months (regression coefficient = -1.9, P < .001) after THA.

CONCLUSIONS

Symptoms of depression on a 2-question preoperative questionnaire are common, and greater symptoms of depression are associated with reduced capability within the first year following THA. These findings support the prioritization of routine mental health assessments before THA. Measuring mindset using relatively brief instruments will be important considering the current shift toward implementing self-reported measures of health status in clinical practice and incorporating them within alternative payment models.

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.

Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients

BACKGROUND

Psychiatric comorbidities have been shown to influence outcomes of various orthopedic pathologies. This study aimed to compare rates of delayed scaphoid union and surgical intervention for fractures in patients with and without comorbid psychiatric diagnoses.

METHODS

A matched retrospective cohort study was performed using the PearlDiver database to determine the association of depression, anxiety, bipolar disorder, and schizophrenia with delayed union rates within 3 and 6 months and rates of nonacute surgical intervention (fixation or grafting) within 6 and 12 months of scaphoid fracture. Analyses were completed using multivariate logistic regression.

RESULTS

Among 20 340 patients, a comorbid psychiatric diagnosis was associated with increased rates of delayed scaphoid union at 3 months (odds ratio [OR] = 1.29; 95% confidence interval [CI], 1.14-1.45) and 6 months (OR = 1.23; 95% CI, 1.10-1.38). At 3 months, women with any psychiatric disorder (OR = 1.58; 1.29-1.66), depression (OR = 1.68; 1.31-2.17), and schizophrenia (OR = 5.32; 95% CI, 1.06-26.79) were more likely to experience delayed union, with similar results at 6 months. Men with bipolar disorder experienced increased delayed union rates at 6 months (OR = 1.40; 1.03-1.91). A comorbid psychiatric diagnosis (OR = 1.10; 1.01-1.20) was associated with increased rates of surgical intervention, whereas schizophrenia was associated with decreased rates (OR = 0.58; 0.34-0.99).

CONCLUSION

Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. These results underscore the importance of understanding factors that may place patients at risk of impaired recovery.

The mind matters: Psychological factors influence subjective outcomes following unicompartmental knee arthroplasty-A prospective study

PURPOSE

This study aimed to investigate how psychological factors, including pain catastrophizing (PC), anxiety and depression affect preoperative and postoperative subjective outcomes in patients undergoing unicompartmental knee arthroplasty (UKA).

METHODS

A prospective comparative study was performed among 150 patients undergoing medial or lateral UKA for isolated unicompartmental osteoarthritis. Patients were categorized based on their preoperative PC and Hospital Anxiety and Depression Scale, stratifying them into groups with PC, anxiety or depression, and those without these psychological factors. Patient-reported outcomes, including the Knee Injury and Osteoarthritis Outcome Score-Physical function Short form (KOOS-PS), 5-level EQ5D Visual Analogue Scale (EQ5D-VAS), Forgotten Joint Score (FJS) and Numeric Rating Scale for pain (NRS-pain) were compared between groups preoperatively and at 6-, 12-, and 24-month follow-up.

RESULTS

At 24 months, PC patients had inferior outcomes in KOOS-PS (66.9 ± 16.5 vs. 77.6 ± 14.7, p = .008), EQ5D-VAS (63.5 ± 19.9 vs. 78.9 ± 20.1, p = .003) and FJS (73.7 ± 14.3 vs. 84.6 ± 13.8, p = .003). Anxiety was associated with inferior KOOS-PS (65.4 ± 15.2 vs. 78.2 ± 14.5, p = <.001), EQ5D-VAS (64.2 ± 23.2 vs. 79.3 ± 19.4, p = .002), FJS (75.7 ± 16.8 vs. 84.6 ± 13.4, p = .008) and NRS-pain (27.4 ± 24.6 vs. 13.7 ± 19.3, p = .023) at 24 months. Depression consistently resulted in inferior outcomes in KOOS-PS, EQ5D-VAS, FJS and NRS-pain across all follow-up assessments (p = <.05). Additionally, patients with anxiety and depression experienced longer length of hospital stay compared to those without these psychological factors (anxiety: 2.3 ± 2.3 vs. 0.8 ± 0.8 days, p = .006; depression: 2.3 ± 2.4 vs. 0.8 ± 0.8 days, p = .017).

CONCLUSIONS

Preoperative PC, anxiety and depression are associated with inferior subjective outcomes both prior to and following UKA. Among these factors, depression seemed to exert the most substantial adverse impact on outcomes following UKA. Patients with anxiety and depression had an extended duration of hospitalization lasting over twice as long as patients without these psychological factors. It seems that inferior outcomes primarily stem from the suboptimal preoperative condition rather than an inherent inability to benefit from UKA.

LEVEL OF EVIDENCE

Level II, prospective study.

The influence of depression on clinical outcomes of total shoulder arthroplasty: a systematic Review

PURPOSE

Much of the current literature on total shoulder arthroplasty (TSA) has assessed the impact of preoperative medical comorbidities on postoperative clinical outcomes. The literature concerning the impact of psychological disorders such as depression on TSA has increased in popularity in recent years, but there lacks a thorough review of the influence of depression on postoperative pain and functional outcomes.

METHODS

We queried PubMed/MEDLINE and identified six clinical studies that evaluated the influence of a psychiatric diagnosis of depression on patient outcomes after TSA. Studies that discussed the impacts of depression on TSA, including PROs or adverse events in adults, were included. Studies focused on other psychologic pathology, non-TSA shoulder treatments, or TSA not for primary osteoarthritis were excluded. Non-clinical studies, systematic reviews, letters to the editor, commentaries, dissertations, books, and book chapters were excluded.

RESULTS

Three cohort studies described patient-reported pain and functional outcomes and three database studies assessed the risk of postoperative complications. Cohort studies demonstrated that the prevalence of depression in patients undergoing TSA decreased from preoperatively to 12-months postoperatively. Two studies demonstrated that depression is an independent predictor of less pre- to postoperative improvement in the ASES score at minimum 2-year follow-up; however, one study found the difference between patients with and without depression did not exceed the minimum clinically important difference. Database studies demonstrated that depression was associated with higher rates of blood transfusion (n = 1, OR = 1.8), anemia (n = 1, OR = 1.65), wound infection (n = 2, OR = 1.41-2.09), prosthetic revision (n = 1, OR = 1.92), and length of hospital stay (n = 3, LOS = 2.5-3 days).

CONCLUSION

Although patients with a preoperative diagnosis of depression undergoing TSA can achieve satisfactory relief of shoulder pain and restoration of function, they may experience poorer patient-reported outcomes and a higher risk of postoperative adverse events compared to their peers. Surgeons should be cognizant of the influence of depression in their patients to facilitate proper patient selection that maximizes patient satisfaction, function, and minimizes the risk of adverse events following TSA.

LEVEL OF EVIDENCE

Level IV.

The Influence of Mental Health Diagnoses on Patient Experiences and Outcomes in Patients Undergoing WALANT Hand Surgery

Purpose

The purpose of this study was to gauge whether patients with preexisting mental health conditions have desirable outcomes when undergoing wide-awake local anesthesia with no tourniquet (WALANT) hand surgery.

Methods

A retrospective review of 133 patients who underwent WALANT surgery by 2 senior authors from August 2019 to October 2020 was performed. Patients were administered a 10-question postoperative survey detailing perioperative pain, experience, and satisfaction concerning their procedure. Analysis was performed for patient responses to the questionnaire, demographics, comorbidities, and patient-reported outcomes using the Single Assessment Numeric Evaluation (SANE).

Results

There were 61 patients identified as having a preexisting psychiatric diagnosis compared to 70 patients without who underwent WALANT surgery. Comparing psychiatric diagnosis and nonpsychiatric diagnosis cohorts, there was no significant difference in preoperative anxiety (3.75 vs 3.30), pain during procedure (0.67 vs 0.56), or pain after surgery (4.89 vs 4.26). There was a significantly higher pain score with preoperative injection in the psychiatric diagnosis cohort (4.07 vs 2.93). When asked if they would have a WALANT procedure again, 95.1% of patients in the psychiatric diagnosis cohort and 98.6% of patients in the nonpsychiatric diagnosis group said they would. There was no significant difference in average preoperative SANE scores (59.67 [no psych diagnosis] vs 61.70 [psych diagnosis]) or postoperative SANE scores (82.82 [no psych diagnosis] vs 81.06 [psych diagnosis]) between the two cohorts.

Conclusions

WALANT surgery was nearly as well tolerated in patients with a preexisting mental health diagnosis when compared to those without a preexisting diagnosis.

Clinical Relevance

Surgeons who are currently or potentially performing WALANT surgery should not rule out patients as eligible candidates because of a prior diagnosis of a mental health condition.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

Mental Health Effects on the Minimal Clinically Important Difference in Total Joint Arthroplasty

INTRODUCTION

The effect of mental health on patient-reported outcome measures is not fully understood in total joint arthroplasty (TJA). Thus, we investigated the relationship between mental health diagnoses (MHDs) and the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in primary TJA and revision TJA (rTJA).

METHODS

Retrospective data were collected using relevant Current Procedural Terminology and MHDs International Classification of Diseases, 10th Revision, codes with completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form, Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, Patient-reported Outcomes Measurement Information System (PROMIS)-Physical Function Short Form 10a, PROMIS Global-Mental, or PROMIS Global-Physical questionnaires. Logistic regressions and statistical analyses were used to determine the effect of a MHD on MCID-I/MCID-W rates.

RESULTS

Data included 4,562 patients (4,190 primary TJAs/372 rTJAs). In primary total hip arthroplasty (pTHA), MHD-affected outcomes for Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (MCID-I: 81% versus 86%, P = 0.007; MCID-W: 6.0% versus 3.2%, P = 0.008), Physical Function Short Form 10a (MCID-I: 68% versus 77%, P < 0.001), PROMIS Global-Mental (MCID-I: 38% versus 44%, P = 0.009), and PROMIS Global-Physical (MCID-I: 61% versus 73%, P < 0.001; MCID-W: 14% versus 7.9%, P < 0.001) versus pTHA patients without MHD. A MHD led to lower rates of MCID-I for PROMIS Global-Physical (MCID-I: 56% versus 63%, P = 0.003) in primary total knee arthroplasty patients. No effects from a MHD were observed in rTJA patients.

DISCUSSION

The presence of a MHD had a prominent negative influence on pTHA patients. Patients who underwent rTJA had lower MCID-I rates, higher MCID-W rates, and lower patient-reported outcome measure scores despite less influence from a MHD.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Post-Traumatic Stress Disorder Is Associated With Increased Emergency Department Services and Similar Rates of Opioid Prescriptions Following Primary Total Hip Arthroplasty: A Propensity Matched Analysis

BACKGROUND

There is a paucity of literature regarding patients who have post-traumatic stress disorder (PTSD) following primary total hip arthroplasty (THA). The purpose of this study was to compare the rates of postoperative complications, prescriptions, health care utilization, and revision arthroplasty of patients who had PTSD undergoing primary THA against a propensity matched control group of patients who did not have PTSD (NPTSD).

METHODS

The TriNetX database was queried to identify PTSD patients undergoing primary THA. Patients were then propensity matched in a 1:1 ratio based on twelve preoperative characteristics to a cohort of NPTSD patients. Postoperative prescriptions and rates of health care utilization were analyzed within 5 days, 14 days, and 1 month postoperatively. Complications were analyzed within one month. Revision arthroplasty rates were analyzed within 1 year and 2 years.

RESULTS

A total of 198,560 patients undergoing primary THA were identified. Ultimately, 1,310 PTSD patients were successfully propensity matched to a cohort of 1,310 NPTSD patients. Patients who have PTSD presented to the emergency department at significantly higher rates than NPTSD patients within 14 days and 1 month postoperatively. Within 1 month postoperatively, cohorts were prescribed opioid analgesics at similar rates (P = .709). Patients who had PTSD received more prescriptions per patient compared to NPTSD patients. Patients who had PTSD were also found to have a higher number of total complications per person within 1 month (P = .022). Within 2 years postoperatively, rates of revision hip arthroplasty were comparable between cohorts (P = .912).

CONCLUSIONS

Patients who have PTSD experience similar rates of revision hip arthroplasty and opioid prescribing compared to NPTSD patients following primary THA; however, within 1 month postoperatively, emergency department visits were greater in PTSD patients. These findings can help delineate early postoperative education and expectations for patients who have PTSD in contrast to other psychiatric diagnoses.

The Association Between Mental Health, Substance Use Disorder, and Outcomes After Total Joint Arthroplasty

BACKGROUND

Prior studies suggest that distressed patients or those who have poor mental health have inferior postoperative outcomes when compared to nondistressed patients. However, these studies typically do not account for substance use or other comorbidities often found in this population, which can independently contribute to postoperative complications. This study sought to control for these factors and assess if a diagnosis of a mental health condition is directly associated with worse outcomes after total joint arthroplasty.

METHODS

A retrospective chart review was performed for 3,182 patients who underwent a total hip arthroplasty and 4,430 patients who underwent a total knee arthroplasty. Diagnosis of the mental health disorders included depression, anxiety disorder, adjustment disorder, bipolar disorder, trauma, stressor-related disorder, and schizophrenia or schizoaffective disorder. Multivariable analyses were performed to control for alcohol use, drug use, tobacco use, body mass index, and a comorbidity index.

RESULTS

When controlling for body mass index and Charlson comorbidity index, no statistically significant associations were found between a diagnosis of any mental health condition or a specific diagnosis of depression or anxiety, and 90-day readmission, reoperation, or 1 year mortality for patients undergoing total knee arthroplasty or total hip arthroplasty.

CONCLUSIONS

When accounting for confounding factors, there does not appear to be a direct association between diagnosis of any of the psychiatric conditions we studied and outcomes after primary total joint arthroplasty. While prior studies suggest addressing the mental health condition may improve outcomes, this study suggests that preoperative medical optimization and potentially addressing substance use may be more effective strategies.

Prevalence and Predictors of Depression in Women with Osteoarthritis: Cross-Sectional Analysis of Nationally Representative Survey Data

Osteoarthritis (OA) is the most common joint disease in the US and can increase the risk of depression. Both depression and OA disproportionately affect women, yet this study is one of few on depression prevalence, treatment across age groups, and predictors in women with OA. Data were extracted from the 2011-March 2020 National Health and Nutrition Examination Survey (NHANES). Women aged ≥ 45 years with self-reported osteo- or degenerative arthritis were included. Outcomes were depression (assessed with PHQ-9) and treatment (self-reported pharmacotherapy and mental health services). Logistic regression was used to examine associations between age group, covariates, and outcomes. Overall, depression prevalence was 8%, with higher proportions among those 45-64 years old. Aging was associated with reduced odds of depression (Age 65-79: OR 0.68 (95% CI: 0.52-0.89); Age 80+: OR 0.49 (95% CI: 0.33-0.74); vs. Age 45-54). Of those with a positive depression screen, 21.6% documented some form of treatment. Age group was not statistically different between those treated and those not treated. Women aged 45-64 with osteoarthritis may be at increased risk of depression, and most are not treated. As depression is related to increased pain and risk of rehospitalization, future research should prioritize interventions to increase uptake of depression treatment.

The association of pre-existing mental health conditions and patient outcomes after lower extremity orthopaedic trauma: a scoping review

INTRODUCTION

Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery, such as pain exacerbations, reduced functional recovery, and lowered patient satisfaction. However, the influence of pre-existing mental health conditions on orthopaedic trauma outcomes has not been thoroughly investigated. The objective of this study was to systematically review literature addressing the association between pre-existing mental health conditions and patient outcomes following surgical interventions for lower extremity fractures in non-geriatric populations.

METHODS

A systematic literature review was conducted using Medline, Embase, and Scopus databases following PRISMA-ScR guidelines to select studies that examined lower extremity orthopaedic trauma outcomes in relation to pre-existing mental health conditions. Studies that evaluated patients with surgically treated lower extremity fractures and a history of mental health conditions such as anxiety, depression, or mood disorders were included. Studies with a mean patient age above 65 years of age were excluded to focus on non-geriatric injury patterns.

RESULTS

The systematic review identified 12 studies investigating the relationship between surgical outcomes of orthopaedic lower extremity fractures and pre-existing mental health disorders in non-geriatric populations. Studies included patients with pelvis, femur, tibia, and ankle fractures. A majority (83%) of these studies demonstrated that patients with pre-existing mental health diagnoses had inferior functional outcomes, heightened pain levels, or an increase in postoperative complications.

DISCUSSION

The presence of pre-existing mental health conditions, particularly anxiety and depression, may predispose orthopaedic trauma patients to an elevated risk of suboptimal functional outcomes, increased pain, or complications after surgical intervention for lower extremity fractures. Future research should focus on interventions that mitigate the impact of mental health conditions on orthopaedic outcomes and patient wellness in this population.

The Association of Season of Surgery and Patient Reported Outcomes following Total Hip Arthroplasty

Background

Understanding the impact of situational variables on surgical recovery can improve outcomes in total hip arthroplasty (THA). Literature examining hospital outcomes by season remains inconclusive, with limited focus on patient experience. The aim of this study is to investigate if there are differences in hospital and patient-reported outcomes measures (PROMS) after THA depending on the season of the index procedure to improve surgeon preoperative counseling.

Methods

A retrospective chart review was performed on patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographic, operative, hospital, and PROMs were gathered from the institutional electronic medical record and our institutional joint replacement outcomes database.

Results

6418 patients underwent primary THA and met inclusion criteria. Of this patient population, 1636 underwent surgery in winter, 1543 in spring, 1811 in summer, and 1428 in fall. PROMs were equivalent across seasons at nearly time points. The average age of patients was 65 (+/- 10) years, with an average BMI of 29.3 (+/- 6). Rates of complications including ED visits within 30 days, readmission within 90 days, unplanned readmission, dislocation, fracture, or wound infection were not significantly different by season (P > .05).

Conclusion

Our findings indicate no differences in complications and PROMs at 1 year in patients undergoing THA during 4 distinct seasons. Notably, patients had functional differences at the second follow-up visit, suggesting variation in short-term recovery. Patients could be counseled that they have similar rates of complications and postoperative recovery regardless of season.

Preoperative Depression Is Associated With Increased Short-term Complications But Equivalent Long-term Outcomes in Total Knee Arthroplasty

Concomitant depression negatively impacts outcomes following total knee arthroplasty (TKA). Patient-Reported Outcomes Measurement Information System (PROMIS) surveys are validated measures that quantify depression, pain, and physical function. We hypothesized that higher preoperative PROMIS-depression scores would be associated with inferior outcomes following TKA. A total of 258 patients underwent primary TKA at a tertiary academic center between June 2018 and August 2020. PROMIS scores were collected preoperatively and at 6 weeks, 3 months, 1 year, and 2 years postoperatively. Patients with preoperative PROMIS depression scores of 55 or greater were considered PROMIS depressed (PD) and patients with scores less than 55 were considered not PROMIS depressed (ND). The primary outcomes were changes in PROMIS scores. Secondary outcomes included total and daily mean morphine milligram equivalents (MME) received during admission as well as 90-day hospital readmission and 2-year all-cause revision rates. There were 66 (25.58%) patients in the PD group and 192 (74.42%) in the ND group. Patients in the PD group had improved depression scores at all follow-up intervals (P<.001) and decreased pain scores at 1 year (P=.016). Both groups experienced similar changes in function scores at each follow-up interval. Patients in the PD group had higher total (P=.176) and daily (P=.433) mean MME use while admitted. Ninety-day hospital readmissions were higher in the PD group (P=.002). There were no differences in 2-year revision rates (P=.648). Preoperative PROMIS-depression scores of 55 or greater do not negatively impact postoperative function, depression, or pain, and patients with these scores have greater improvement in depression and pain at certain intervals. Patients in the PD group had higher readmission rates. [Orthopedics. 2024;47(1):40-45.].

Post-traumatic stress disorder is more likely in younger patients undergoing lower limb arthroplasty: impact on function and quality of life

INTRODUCTION

The aim of this study was to assess whether PTSD was associated with preoperative and/or postoperative joint-specific function and health-related quality of life (HRQoL) in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) and whether there were associated preoperative factors.

METHODS

A retrospective study was conducted at a single centre using an established arthroplasty database over a 2-year period. Patients undergoing THA and TKA completed pre and 1-year postoperative Oxford hip/knee scores and EuroQoL questionnaire (EQ-5D) to assess joint specific function and HRQoL. Postoperatively, patients completed the self-reported PTSD Checklist for DSM-5 (PCL-5) questionnaire where a score of 31 or greater was used to determine a provisional diagnosis of PTSD.

RESULTS

There were 1244 THA and 1356 TKA patients, of which 42 (3.4%) and 54 (4.0%) had a PCL-5 score of ≥ 31, respectively (PTSD groups). Younger age was associated (p < 0.001) with PTSD for both THA (mean difference (MD) 9.9, 95%CI 6.7-13.0) and TKA (MD 4.6, 95%CI 2.2-6.9), which remained significant when adjusting for confounding variables (THA: p < 0.001; TKA: p = 0.020). The preoperative Oxford (THA:MD 4.9, p < 0.001; TKA:MD 5.7, p < 0.001) and EQ-5D scores (THA:MD 0.378, p < 0.001; TKA:MD 0.276, p < 0.001) were significantly worse in the PTSD groups. Age (AUC 73.8%, p < 0.001) and EQ-5D (AUC 72.9%, p < 0.001) were independent factors that were predictive of PTSD in patients undergoing THA and TKA, respectively. When adjusting for confounding variables, PTSD was clinically and statistically significantly (p < 0.001) associated with a lower improvement in the Oxford (THA:MD 9.3; TKA:MD 10.0) and EQ-5D (THA:MD 0.375; TKA:MD 0.293) scores.

CONCLUSIONS

One in 25 patients met a provisional PTSD diagnosis; they were younger and had worse preoperative and improvement in postoperative joint specific function and HRQoL. Age and EQ-5D could be used to identify patients at risk.

Assessing perceived participation among older adults total hip arthroplasty and total knee arthroplasty patients six months post-surgery: a cross-sectional study

Aims

This research sought to assess the perceived levels of participation and autonomy in senior patients who had received total hip arthroplasty (THA) or total knee arthroplasty (TKA) in Hangzhou, China. Furthermore, the study aimed to identify the factors linked to these outcomes.

Study design

This investigation will utilize a cross-sectional study design to assess perceived participation and autonomy among older adults total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. The research was conducted in Hangzhou, China, at a tertiary hospital.

Methods

Convenient sampling was utilized to select 139 patients who underwent THA or TKA between March 2022 and March 2023 and met the inclusion criteria at a tertiary hospital in Hangzhou. The Impact on Participation and Autonomy Questionnaire, Hip/Knee Injury and Osteoarthritis Outcome Score (HOOS/KOOS), 5-Item Geriatric Depression Scale, Multidimensional Scale of Perceived Social Support, and Elders Health Empowerment Scale were used to assess perceived participation, hip/knee-related symptoms and functional restrictions, depression symptoms, social support, and health empowerment.

Results

The mean score for perceived participation and autonomy was 22.554 (SD: 13.042). The mean scores for participation in indoor autonomy, outdoor autonomy, family roles, and social relations were 0.654 (SD: 0.608), 1.324 (SD: 0.792), 1.053 (SD: 0.657), and 0.664 (SD: 0.542), respectively. Negative correlations were observed between perceived participation/autonomy scores and HOOS/KOOS, social support, and health empowerment scores. Conversely, a positive correlation was found between perceived participation/autonomy scores and depression scores. The detrimental effect of HOOS/KOOS, social support, and health empowerment scores on perceived participation and autonomy was notable, while the impact of depressive symptoms was comparatively minor.

Conclusion

Older Chinese patients, at first six months post THA/TKA surgery, reported higher levels of perceived participation compared to individuals with other conditions, such as stroke patients. Functional limitations resulting from hip/knee-related symptoms, as well as social support and health empowerment, emerged as significant influencing factors for perceived participation and autonomy. This research enhances our comprehension of the elements influencing perceived participation among older adults individuals who have undergone THA/TKA procedures.

Mental health disorders and pain modulation in orthopedic shoulder patients

Background

Various studies have examined the relationship between preoperative mental health diagnoses (MHDs) and postoperative outcomes in orthopedic shoulder patients. However, few investigations delve into the relationship between a preoperative MHD and postoperative opioid pain control regimens in patients who have undergone rotator cuff repair (RCR), total shoulder arthroplasty (TSA), and reverse TSA (rTSA). We hypothesize that orthopedic shoulder patients with a preoperative MHD will be prescribed more opioids (ie, request more refills) postoperatively than those without a MHD.

Methods

An institutional review board-approved retrospective chart review was performed on 438 patients, 18 years or older, who underwent RCR, TSA, or rTSA. Patients were divided into two groups: those diagnosed with depression, anxiety, bipolar disorder, and/or schizophrenia (n = 193), and those with no previous MHD (n = 245). Statistical outcomes were analyzed with the independent t-test, Mann-Whitney U test, one-way Analysis of Variance, and Kruskal-Wallis test.

Results

Univariate analysis demonstrated significant differences between the MHD group and non-MHD group in average 90-day postoperative opioid scripts (2.10 vs. 1.55, respectively, P < .001) and median 90-day postoperative morphine milligram equivalents (MMEs) prescribed (225 MME vs. 185.25 MME, respectively, P < .001). Among patients who were opioid naive 90 days preoperatively, significant differences were found in MMEs prescribed between the MHD and non-MHD group (225 MME vs. 150 MME, respectively, P < .001). Further analysis of opioid naive patients with specifically depression compared to patients with an alternate or no MHD diagnosis yielded significant differences in scripts (1.78 vs. 1.33, respectively, P = .031) and MMEs prescribed (225 MME vs. 150 MME, respectively, P < .001).

Conclusion

This study found that RCR, TSA, or rTSA patients with a preoperative MHD were prescribed significantly more postoperative MMEs and more opioid scripts (ie, requested more refills) than those without MHD. This is despite preoperative education on postoperative pain expectations and limiting opioid use. Our findings support our hypothesis and emphasize the clinical importance of recognizing mental health disease while navigating postoperative pain control expectations. Given the rising prevalence of mental health disorders nationwide, considering the effect of these comorbidities on postoperative pain in RCR, TSA, and rTSA patients will be essential to enhance preoperative and postoperative counseling and management by orthopedic surgeons. We further recommend a multidisciplinary approach to help manage pain in these patients.

Do You PROMIS (Patient Reported Outcomes Measurement Information System)? Physical Function and Pain Interference Scores After Total Knee and Hip Arthroplasty

Background

Physical function and pain outcomes vary after arthroplasty. We investigated differences in postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores for patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to identify preoperative factors that predict postoperative PROMIS scores.

Methods

Patients who underwent TKA and THA from 2014-2020 were eligible. Preoperative variables including demographics, comorbidities, and pain scores were obtained from the medical record. Patients completed surveys measuring postoperative PF and PI. Descriptive statistics and separate linear regression models for each anatomical location were performed to examine factors predicting postoperative PROMIS PF and PI scores.

Results

Surveys were completed by 2411 patients (19.5% response rate). Unadjusted mean PF postoperative scores were 47.2 for TKA and 48.8 for THA. Preoperative predictors of lower PF included female sex; body mass index and comorbidities for TKA and THA; and age, tobacco use, and non-White race for THA. Mean PI scores were 47.9 for THA and 49.0 for TKA. Preoperative predictors of increased PI included non-White race and increased body mass index for TKA and THA; higher preoperative pain for TKA; and female sex and increased comorbidity for THA.

Conclusions

Postoperative PROMIS scores were similar for TKA and THA, with THA having slightly higher PF and lower PI scores. Regression models using preoperative variables showed similar performance for TKA compared with THA. These findings suggest areas for future development of clinical decision support tools.

Association of Preoperative Depression Score With Outcomes of Transfibular Total Ankle Arthroplasty

Favorable short-term results of transfibular total ankle arthroplasty have been reported in several studies; however, the factors affecting these results have not been elucidated. This study aimed to determine whether preoperative depression affects the outcome of transfibular total ankle arthroplasty and whether depression changes with surgery. Scores from the Japanese Society of Surgery of the Foot Ankle/Hindfoot scale (JSSF scale), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), Hospital Anxiety and Depression Scale (HADS), and Timed Up & Go test (TUG) were collected preoperatively, at 6 months, and at 1 year postoperatively from 20 patients. Eighteen patients were diagnosed with osteoarthritis and 2 patients with rheumatoid arthritis. The mean age of the patients was 75 years. Patients were divided into 2 groups: those with preoperative HADS depression scores above the median (higher depression score group) and below the median (lower depression score group), and intergroup comparisons were made. No significant differences were observed in the JSSF and TUG scores between the groups, both preoperatively and postoperatively. Meanwhile, the SAFE-Q pain subscale score was significantly lower in the higher depression score group than in the lower depression score group (median, 59 vs 90) 1 year postoperatively. There were no differences in the other SAFE-Q subscale scores between the groups. The results suggested that depressive tendencies did not affect postoperative functional results using objective assessment measures but had a negative impact on pain in subjective assessment measures.

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.

Significant Analgesic Benefits of Perioperative Duloxetine in Patients Who Have Depressive Symptoms Undergoing Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Major symptoms of depression are commonly observed in patients requiring total hip arthroplasty (THA), and this is associated with increased pain scores and opioid consumption. We aimed to investigate the analgesic effect of duloxetine in these high-risk patients.

METHODS

Among 263 patients scheduled for primary unilateral THA, 67 patients who scored at least 8 on the 17-item Hamilton Depression Scale (HAMD) were enrolled in this study. Patients were randomized to the duloxetine group (60 mg daily, from the day of surgery to postoperative day 6) or the placebo group. The postoperative visual analog scale (VAS) score during walking, the VAS score during hip flexion, and resting VAS score was measured. Postoperative morphine consumption, hip range of motion (ROM), Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, postoperative length of stay (LOS), and adverse events were recorded.

RESULTS

The duloxetine group had significantly lower VAS scores during walking and hip flexion from postoperative day 3 to week 3 than the placebo group. With regard to the resting VAS score, duloxetine showed a better analgesic effect from postoperative day 3 to week 2 than placebo. Patients in the duloxetine group had less consumption of morphine. The duloxetine group exhibited better hip function scores, including ROM, HHS, and WOMAC function scores than the placebo group. No significant difference was observed in LOS or adverse events between groups.

CONCLUSION

Perioperative short-term duloxetine provides advantages in decreasing pain, reducing morphine consumption, and increasing hip function in THA patients who have depressive symptoms.

Does resilience predict hospital length of stay after total knee arthroplasty? A prospective observational cohort study

Background

Resilience, or the ability to bounce back from stress, is a key psychological factor that is associated with ongoing functional independence and higher quality of life in older adults in the context of chronic health conditions. Emerging research has explored resilience and patient-reported outcomes after TKA. Our primary aim was to explore the relationship between resilience and acute hospital length of stay after total knee arthroplasty (TKA).

Methods

A prospective observational study recruited 75 participants one month before total knee arthroplasty from two Australian hospitals. Two preoperative psychological measures were used: the Brief Resilience Scale, and for comparison, the Depression, Anxiety and Stress Scale-21 (DASS-21). We collected sociodemographic, medical and surgical details, patient-reported pain, function, fatigue and quality of life one month before TKA. Health service data describing acute hospital length of stay, inpatient rehabilitation use, and physiotherapy occasions of service were collected after TKA. Non-parametric analysis was used to determine any differences in length of stay between those with low or high resilience and DASS-21 scores. Secondary regression analysis explored the preoperative factors affecting acute hospital length of stay.

Results

No significant difference was detected in length of stay between those with a low or a high resilience score before TKA. However, the group reporting psychological symptoms as measured by the DASS-21 before TKA had a significantly longer acute hospital length of stay after TKA compared to those with no psychological symptoms [median length of stay 6 (IQR 2.5) days vs. 5 (IQR 2) days, respectively (Mann-Whitney U = 495.5, P=0.03)]. Multivariate regression analysis showed that anesthetic risk score and fatigue were significant predictors of length of stay, with the overall model demonstrating significance (χ2=12.426, df = 4, P=0.014).

Conclusions

No association was detected between the brief resilience score before TKA and acute hospital length of stay after TKA, however, symptoms on the DASS-21 were associated with longer acute hospital length of stay. Preoperative screening for psychological symptoms using the DASS-21 is useful for health services to identify those at higher risk of longer acute hospital length of stay after TKA.

Efficacy and safety of tanezumab, NSAIDs, and placebo in patients with moderate to severe hip or knee osteoarthritis and a history of depression, anxiety, or insomnia: post-hoc analysis of phase 3 trials

Objective: Treatment outcomes for chronic pain can be poor in patients with depression, anxiety, or insomnia. This analysis evaluated the efficacy and safety of subcutaneous tanezumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and placebo in patients with osteoarthritis (OA) and a history of these conditions using data from three phase 3 studies.Methods: A post-hoc analysis of data from two pooled placebo-controlled studies and one NSAID-controlled study of subcutaneous tanezumab. All patients had moderate to severe knee or hip OA that was inadequately controlled with standard-of-care analgesics. Efficacy outcomes were least-squares mean change from baseline to Week 16 in Western Ontario McMaster Universities OA Index (WOMAC) Pain, WOMAC Physical Function, Patient's global assessment of OA, and EQ-5D-5L scores. Results were summarized for patients with and without a history of depression, anxiety, or insomnia at baseline.Results: 1545 patients were treated in the pooled placebo-controlled studies (history of depression, 12%; anxiety, 8%; insomnia, 10%; any, 23%) and 2996 in the NSAID-controlled study (16%, 11%, 13%, 28%, respectively). In groups with positive histories, 38-80% took antidepressant or anxiolytic medications at baseline. Within treatments, largely similar improvements in efficacy outcomes were observed in patients with and without a history of depression, anxiety, or insomnia; the types of treatment-emergent adverse events were similar.Conclusions: Patients with OA and a history of depression, anxiety, or insomnia did not appear to experience reduced efficacy outcomes or an altered safety profile in response to tanezumab or NSAID treatment as compared with those without. NCT02697773; NCT02709486; NCT02528188.

Effects of veterans' mental health service-connections on patient-reported outcomes following total joint arthroplasty

Background

Studies report poor outcomes of elective orthopaedic surgeries among civilian patients receiving Workers' Compensation (WC). However, little is known about surgical outcomes in veterans receiving similar benefits through the Veterans Affairs (VA) service-connected (SC) disability compensation program.

Methods

Veterans undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a VA Medical Center between 07/2019-12/2021 were analyzed by SC status. Outcomes were evaluated using Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores collected preoperatively and at 2- and 12-months postoperatively. Repeated measures mixed models were used to test for the effect of SC on HOOS-JR/KOOS-JR scores, controlling for baseline age, sex, and Charlson Comorbidity Index (CCI). SC and baseline joint function (stratified into quartiles using baseline HOOS-JR/KOOS-JR scores) were analyzed for effects on achieving substantial clinical benefit (SCB) at 12-month follow-up.

Results

The analysis included 67 hips and 142 knees. SC and non-SC (NSC) veterans had similar baseline HOOS-JR/KOOS-JR and CCI. HOOS-JR remained similar between groups through 12 months (79.9 ± 19.2 vs. 82.7 ± 18.8) as did KOOS-JR (70.4 ± 15.6 vs. 74.6 ± 15.3). The designation of any SC and mental health SC reached significance for KOOS-JR (P = 0.034 and P = 0.032, respectively). For HOOS-JR and KOOS-JR, baseline function score quartile significantly influenced final score (P < 0.001), with patients in the lowest quartiles (i.e., worst baseline function) exhibiting significantly greater improvements than patients in higher quartiles.

Conclusions

Mental health SC and high preoperative functional status are variables that may have unfavorable influences on self-reported outcomes of TKA in veteran patients. SC status does not appear to influence the outcomes of THA or the likelihood of achieving SCB after either THA or TKA. Regardless of SC status, most veterans can expect significant clinical improvements after total joint arthroplasty.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BACKGROUND

Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.

METHODS

This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.

RESULTS

The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.

CONCLUSIONS

Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Development of Reliable and Valid Negative Mood Screening Tools for Orthopaedic Patients with Musculoskeletal Pain

BACKGROUND

Negative mood is an important risk factor for poor clinical outcomes among individuals with musculoskeletal pain. Screening for negative mood can aid in identifying those who may need additional psychological interventions. Limitations of current negative mood screening tools include (1) high response burden, (2) a focus on single dimensions of negative mood, (3) poor precision for identifying individuals with low or high negative mood levels, and/or (4) design not specific for use in populations with orthopaedic conditions and musculoskeletal pain.

QUESTIONS/PURPOSES

(1) Can item response theory methods be used to construct screening tools for negative mood (such as depression, anxiety, and anger) in patients undergoing physical therapy for orthopaedic conditions? (2) Do these tools demonstrate reliability and construct validity when used in a clinical setting?

METHODS

This was a cross-sectional study involving outpatients having physical therapy in tertiary-care settings. A total of 431 outpatients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions were enrolled between December 2014 and December 2015, with 24% (103 of 431) seeking care after orthopaedic surgery. Participants completed three validated psychological questionnaires measuring negative mood, resulting in 39 candidate items for item response theory analysis. Factor analysis was used to identify the dimensions (factors) assessed by the candidate items and select items that loaded on the main factor of interest (negative mood), establishing a unidimensional item set. Unidimensionality of an item set suggests they are assessing one main factor or trait, allowing unbiased score estimates. The identified items were assessed for their fit to the graded item response theory model. This model allows for items to vary by the level of difficulty they represent and by their ability to discriminate between patients at different levels of the trait being assessed, in this case, negative mood. Finally, a hierarchical bifactor model where multiple subfactors are allowed to load on an overall factor was used to confirm that the items identified as representing a unidimensional item set explained the large majority of variance of the overall factor, providing additional support for essential unidimensionality. Using the final item bank, we constructed a computer adaptive test administration mode, and reduced item sets were selected to create short forms including items with the highest information (reliability) at targeted score levels of the trait being measured, while also considering clinical content.

RESULTS

We identified a 12-item bank for assessment of negative mood; eight-item and four-item short-form versions were developed to reduce administrative burden. Computer adaptive test administration used a mean ± SD of 8 ± 1 items. The item bank's reliability (0 = no reliability; 1 = perfect reliability) was 0.89 for the computer adaptive test administration, 0.86 for the eight-item short form, and 0.71 for the four-item short form. Reliability values equal to or greater than 0.7 are considered acceptable for group level measures. Construct validity sufficient for clinical practice was supported by more severe negative mood scores among individuals with a previous episode of pain in the involved anatomical region, pain and activity limitations during the past 3 months, a work-related injury, education less than a college degree, and income less than or equal to USD 50,000.

CONCLUSION

These newly derived tools include short-form and computer adaptive test options for reliable and valid negative mood assessment in outpatient orthopaedic populations. Future research should determine the responsiveness of these measures to change and establish score thresholds for clinical decision-making.

CLINICAL RELEVANCE

Orthopaedic providers can use these tools to inform prognosis, establish clinical benchmarks, and identify patients who may benefit from psychological and/or behavioral treatments.

Depression in Osteoarthritis: Current Understanding

Depression, one of the most common comorbidities with osteoarthritis (OA), affects patient prognosis and quality of life. It also increases the overall burden of disease. This subgroup of patients has not been effectively managed in clinical settings. The study aimed to direct physicians' attention to the co-occurrence of depression and OA. Therefore, this review summarizes the relevant literature published over the past 10 years. The focus is on the prevalence of and risk factors for depression in OA, the effects of depression on OA development and treatment response, comorbidity mechanisms, screening, and non-pharmacological treatment. The research on the etiology of depression has been driven largely by epidemiological studies. Recent studies have shown that high levels of pain, poor levels of function, high numbers of OA sites, and slow gait might be associated with depression. However, the pathophysiology of OA and depression comorbidities remains unclear. In addition to immune inflammation and structural changes in the brain, which have been documented in brain imaging studies, psychosocial factors may also play a role. The evidence indicates that depression can be treated with early intervention; however, adjustments may need to be made for individuals with comorbid depression in OA. It is recommended that health care providers pay more attention to depressive symptoms in patients with OA. Clinicians should develop and implement an individualized and comprehensive treatment plan for patients based on a mental health assessment and in teams with other professionals to optimize treatment outcomes.