¿Influye la ansiedad y depresión preoperatorias en los resultados de la artroplastia de rodilla?

Literature Review to Understand the Burden and Current Non-surgical Management of Moderate-Severe Pain Associated with Knee Osteoarthritis

INTRODUCTION

To conduct a literature review exploring the humanistic burden, costs, and guideline recommendations for non-surgical management of moderate-severe pain in knee osteoarthritis (KOA).

METHODS

Published studies (2018-25 April 2023) assessing the burden of moderate-severe pain in KOA were identified by searching Medline, Embase, EconLit, and Cochrane database, supplemented with grey literature hand searches and reference list snowballing. Treatment guidelines were also identified for key countries.

RESULTS

This review included 106 publications and 37 treatment guidelines. Patients with moderate-severe pain were found to experience a low quality of life (QoL) and an impaired ability to perform daily tasks. The economic burden of KOA was substantial, including cost of medical visits, non-operative treatment (physical therapy and hyaluronic acid [HA] being key drivers) and productivity losses. Non-steroidal anti-inflammatory drugs (NSAIDs) were among the most frequently used pharmacological treatments, with intra-articular (IA) injections used to varying degrees. Opioid use was also frequently reported. Guidelines universally recommended NSAIDs, albeit with limited dose and duration for oral NSAIDs. IA-corticosteroids were conditionally/moderately recommended for short-term use by most guidelines, while IA-HA and opioids were rarely recommended. Guidelines are not specific to patients with moderate-severe pain and do not distinguish between different KOA phenotypes.

CONCLUSIONS

KOA with moderate-severe pain is associated with substantial humanistic and economic burden. Real-world data suggest that some treatments are regularly used at high cost regardless of the lack of evidence-based recommendations. There remains a need for new treatment options that successfully relieve pain, improve QoL and delay the need for surgery. Graphical abstract available for this article.

Introducing a specified on-line multimodal prehabilitation approach for total knee replacement surgery candidates using data from the COVID-19 pandemic: An exploratory field-based, pre-post, mixed methods implementation pilot study

RATIONALE

Individuals waiting for total-knee-replacement surgery are at risk of developing morbidities and frailty which may affect their postoperative recovery. Multi-modal prehabilitation could mitigate these unintentional effects.

AIMS AND OBJECTIVES

To implement and evaluate a specified online multi-modal prehabilitation intervention in patients waiting for total-knee-replacement surgery in a large urban acute hospital trust.

METHOD

A non-randomised, pre/post analysis implementation pilot with a nested qualitative study was conducted and is reported following the standards for implementation studies (StaRI) guidance. Of 35 listed cases, 12 (34%) were eligible, recruited, and completed an 8-week multi-modal online intervention incorporating 5 modalities (i) cardiovascular exercise, (ii) strength/balance function, (iii) smoking cessation, (iv) opioid use, (v) nutritional intake. Interventions were specified using the Rehabilitation Treatment Specification System, where rehabilitation treatment theory accounts for discrete treatment components. Two participated in an online qualitative interview post-intervention. Process evaluation included intervention fidelity, eligibility/recruitment/retention rates, and clinical outcomes included knee function, frailty, gait velocity, anxiety/depression, and quality of life.

RESULTS

Five participants (42%) completed the intervention and were retained at follow-up. The intervention was delivered online at specified doses, frequency/durations indicative of high respective adherence, quantity, and exposure fidelity. There was significant improvement in median oxford knee score (p = 0.015), gait velocity (p = 0.040) and anxiety (p = 0.023). The interview revealed 5 themes; surgery preconceptions, motivation, acceptability, postoperative experiences, and future recommendations confirming acceptance of the intervention by virtue of adhering to the treatment exposure delivered as planned.

CONCLUSION

The specified multi-modal prehabilitation was acceptable, implementable, and demonstrated evidence of preliminary efficacy. Further experimental pilot work that represents the spectrum of frailty, obesity, quality of life, and comorbidities associated with total-knee-replacement surgery is indicated.

The Relationship Between Preoperative Anxiety Level and Postoperative Pain Outcomes in Total Hip and Knee Replacement Surgery: A Cross-sectional Study

PURPOSE

Preoperative anxiety is considered a common part of the surgerical experience and can be associated with serious postoperative side effects. This study aims to determine the relationship between preoperative anxiety level and postoperative pain outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR).

DESIGN

The study used a cross-sectional and correlational research method.

METHODS

The study was conducted with a total of 104 participants, who underwent 17 THR and 87 TKR, at the Orthopedic Clinic of a state hospital in southern Turkey between June 2021 and June 2022. The State-Trait Anxiety Inventory (STAI) was used to determine preoperative anxiety level, and the Visual Analog Scale (VAS) and the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) were used to assess postoperative pain level.

FINDINGS

The mean preoperative STAI-I and STAI-II scores of the participants who underwent THR and TKR were 53.95 ± 10.51 and 44.20 ± 10.55, respectively. There was a moderate positive correlation between STAI-I scores and VAS pain scores at preoperative and postoperative 6th, 12th, 24th, and 36th hours. There was a moderate positive correlation between STAI-I scores and affective subdimension scores, a moderate positive correlation with pain severity and sleep interference and activity interference, and a weak positive correlation between STAI-II scores and pain severity and sleep interference, activity interference and affective. The factors independently affecting the 6th-hour VAS pain score were determined as male gender, THR procedure, and increasing STAI score.

CONCLUSIONS

We found that high preoperative state anxiety was associated with early postoperative pain outcomes. State anxiety was associated with pain in the 6th postoperative hour. Considering the multidimensional nature of anxiety, further research is recommended to understand the anxiety domain in surgical patients.

Factors Correlated with the Quality of Life after Total Knee Arthroplasties: A Literature Review

Introduction

Total Knee Arthroplasty (TKA) has been widely reported to improve outcomes and quality of life (QoL) in patients with knee osteoarthritis (KOA), but there are still 15 - 20% of patients still experience pain, physical limitations, and other complications after TKA. Therefore, it is necessary to identify various factors that correlate with QoL from current evidence. The objective is to review the literature on factors that correlate with QoL in patients who underwent TKA.

Materials and methods

A literature search was conducted on five databases, i.e. ProQuest, CINAHL, Medline, Embase, and Scopus, using the following keywords: total knee arthroplasty (TKA), post-operative, quality of life (QoL), and outcome. There were no restrictions on the research design.

Results

This review found 14 articles (7 prospective studies and 7 retrospective studies) involving 15,972 patients who underwent TKA, with an age range of 32 - 94 years. All articles reported improvement in QoL after TKA. The review revealed 30 factors, of which 15 factors were significantly correlated with QoL after TKA. The factors were grouped into four types: demographic, socioeconomic, clinical, and psychosocial factors.

Conclusion

Information regarding factors that correlate with QoL after TKA can be used for directing treatment and discharge planning according to the patient's factors.

Evaluation of Neuropathic Pain after Total Knee Arthroplasty: Do Yellow Flags Matter?

Up to 20% of total knee arthroplasty (TKA) patients continue to experience chronic postsurgical pain. Various factors have been identified as potential contributors, including so-called "yellow flags", encompassing symptoms of depression, anxiety, and catastrophizing, which were examined in this study to assess their predictive value concerning functional outcomes after TKA.

METHODS

Fifty TKA patients were categorized into high-risk and low-risk groups based on clinical assessment, demographic data, medication, and patient-reported outcome measures (DN4, SF-36, WOMAC, NRS, Fibromyalgia Survey Questionnaire, Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale). Postoperative outcomes within six months after TKA were then compared.

RESULTS

Both groups exhibited significant (p < 0.001) improvements in all WOMAC and NRS subscales, as well as in the physical function, role physical, pain, and energy/fatigue subdomains of the SF-36 after six months, while the high-risk group showed lower WOMAC scores regarding stiffness (19.0 ± 18.3 vs. 27.2 ± 20.7, p < 0.001) and pain (13.5 ± 13.3 vs. 15.1 ± 16.3, p = 0.029). The high-risk group showed significantly worse preoperative DN4 scores (1.8 ± 1.3 vs. 3.0 ± 1.1, p = 0.002) than the low-risk group, which persisted for one day (2.3 ± 1.2 vs. 3.5 ± 1.5, p = 0.005) and six weeks (2.2 ± 1.9 vs. 3.6 ± 2.3, p = 0.041) postoperatively.

CONCLUSIONS

Our results indicate that pre-existing yellow flags contribute to a more challenging early postoperative phase, underscoring the importance of considering individual patient characteristics and psychological factors to optimize TKA outcomes.

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.

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient

BACKGROUND

Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications.

METHODS

This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses.

RESULTS

Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001).

CONCLUSION

Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

Effectiveness of a Nursing Intervention to Diminish Preoperative Anxiety in Patients Programmed for Knee Replacement Surgery: Preventive Controlled and Randomized Clinical Trial

OBJECTIVES

This work was conducted to determine the effectiveness of a nursing intervention, based on the motivational interview, to diminish preoperative anxiety in patients programmed for knee replacement surgery.

METHODS

Preventive type controlled and randomized clinical trial, on a sample of 56 patients programmed for knee replacement surgery in a clinic in Girardot (Colombia). Random assignment was made: an intervention group (n=28) and a control group (n=28). The six-question Amsterdam Preoperative Anxiety and Information Scale was applied before and after the intervention. The scale has a total score ranging from 5 to 30; the higher the score, the greater the preoperative anxiety. The nursing intervention was conducted in three sessions of motivational interview each lasting 40 min, during the six weeks prior to the surgical procedure; the control group received conventional management of education in the health institution.

RESULTS

The mean score of preoperative anxiety was equal in the pre-intervention evaluation in both groups (19.76 in the experimental versus 22.02 in the control =22.02; p<0.226), while during the post-intervention, the anxiety score was lower in the intervention group compared with the control group (15.56 and 20.30, respectively; p <0.013).

CONCLUSIONS

Nursing intervention based on the motivational interview was effective in diminishing preoperative anxiety in patients programmed for knee replacement surgery.