Influence of the emotional response to surgery on functional recovery during 6 months after hip arthroplasty

Early functional recovery outcomes and return to work after primary total hip arthroplasty: a novel patient reported outcomes questionnaire

PURPOSE

Clinical and patient reported outcomes are often collected before and after the procedure to benchmark and study outcomes for patients. These outcomes and scores are useful for tracking patient outcomes after surgery, however, the fact that these commonly used measures typically provide information about a patient's level of pain and function at a single point in time is a limitation.

METHODS

We present early functional recovery and return to work outcomes after primary THA from a novel questionnaire administered in a global, multi-center, prospective clinical study.

RESULTS

By 6 and 12 weeks post-op, a large proportion of study subjects were able to perform functional recovery outcomes after their THA: walk without an aid (74%; 94%); drive (76%; 97%); basic activities of daily living (94%; 99%); perform light household duties (91%; 96%); perform moderate-to-heavy household duties (54%; 86%); go up and down a flight of stairs (92%; 99%); put on socks/stockings (77%; 93%); bend down to pick up an object from the floor (87%; 97%); stand up from a chair (96%; 99%); perform leisure recreational activities (54%; 84%); perform primary goal identified pre-THA (69%; 86%). 60% were able to return to work by 12 weeks post-op. These questions showed strong association with the Forgotten Joint Score.

CONCLUSION

Excellent patient reported early functional recovery outcomes and satisfaction were observed at 6- and 12-weeks post-op in this cohort and is the first reported data using a novel PRO.

CLINICAL TRIAL REGISTRATION

NCT03189303, registered June 14, 2017.

Systematic review: preoperative psychological factors and total hip arthroplasty outcomes

Background

Total hip arthroplasties (THA) are cost-effective interventions for patients with osteoarthritis refractory to physical therapy or medical management. Most individuals report positive surgical outcomes with reduction in pain and improved joint function. Multiple recent studies demonstrated the influence of patient mental health on surgical success. We sought to determine the relationship between patient preoperative psychological factors and postoperative THA outcomes, specifically pain and function.

Methods

PubMed, EMBASE and Cochrane Reviews databases were queried using terms “(mental OR psychological OR psychiatric) AND (function OR trait OR state OR predictor OR health) AND (outcome OR success OR recovery OR response) AND total joint arthroplasty).” A total of 21 of 1,286 studies fulfilled inclusion criteria and were included in the review. All studies were analyzed using GRADE and Risk of Bias criteria.

Results

Overall, compared to cohorts with a normal psychological status, patients with higher objective measures of preoperative depression and anxiety reported increased postoperative pain, decreased functionality and greater complications following THA. Additionally, participants with lower self-efficacy or somatization were found to have worse functional outcomes.

Conclusions

Preoperative depression, anxiety and somatization may negatively impact patient reported postoperative pain, functionality and complications following THA. Surgeons should consider preoperative psychological status when counseling patients regarding expected surgical outcomes.

Level of evidence

3.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03355-3.

Investigating the True Effect of Psychological Variables Measured Prior to Arthroplastic Surgery on Postsurgical Outcomes: A P-Curve Analysis

Patients' presurgical psychological profiles have been posited to predict pain and function following arthroplastic surgery of the hip and knee. Nevertheless, findings are conflicting, and this may be rooted in biased reporting that makes the determination of evidential value difficult. This ambiguity may have negative consequences for researchers and governmental agencies, as these rely on findings to accurately reflect reality. P-Curve analyses were used to establish the presence of evidential value and selective reporting in a sample of studies examining the effect of presurgical psychological predictors on outcomes following knee and hip arthroplastic surgery. A systematic search of the literature revealed 26 relevant studies. The examined sets of studies indicate that there is evidential value for the effect of depression on pain intensity and function, anxiety on pain intensity and function, pain catastrophizing on pain intensity, as well as the combined effects of all psychological predictors on pain intensity and function. The presence of evidential value was inconclusive for the effect of optimism on pain intensity. There were no signs that any results were influenced by biased reporting. The results highlight the importance of patients' psychological profiles in predicting surgical outcomes, which represent a promising avenue for future treatment approaches. PERSPECTIVE: The effects of P-hacking are difficult to detect and might be at the root of conflicting findings pertaining to the predictive properties of presurgical psychological variables on postsurgical outcomes. P-Curve analysis allows the determination of evidential value underlying these relationships and detection of P-hacking to ensure that findings are not the result of selective reporting.

Prognostic factors for inpatient functional recovery following total hip and knee arthroplasty: a systematic review

Background and purpose - Essential for safe and timely hospital discharge, inpatient functional recovery following lower limb arthroplasty is also variable. A previous systematic review reported moderate and conflicting levels of evidence regarding patient-related predictors of inpatient recovery for primary total hip arthroplasty (THA). A systematic review of surgical prognostic factors for inpatient recovery following THA or total knee arthroplasty (TKA) is yet to be undertaken. We identified patient and surgical prognostic factors for inpatient functional recovery following THA and TKA; determined whether inpatient functional recovery varies between these procedures; and established whether validated outcome measures relevant to the patient's functional requirements for hospital discharge are routinely assessed.Patients and methods - Critical Appraisal Skills Programme checklists assessed methodological quality, and a best-evidence synthesis approach determined the levels of evidence supporting individual prognostic factors. PubMed, CINAHL, Embase, Scopus, and PEDro databases were searched from inception to May 2019. Included studies examined patient or surgical prognostic factors and a validated measure of post-operative function within 2 weeks of primary, unilateral THA or TKA.Results - Comorbidity status and preoperative function are supported by a strong level of evidence for TKA. For THA, no strong level of evidence was found for patient-related prognostic factors, and no surgical factors were independently prognostic for either arthroplasty site. Limited evidence supports fast-track protocols in the TKA population.Interpretation - Preoperative screening and optimization is recommended. Assessment of Enhanced Recovery Pathways using validated outcome measures appropriate for the early postoperative period is warranted.

Preoperative psychosocial factors predicting patient's functional recovery after total knee or total hip arthroplasty: a systematic review

OBJECTIVE

To evaluate the predictive value of preoperative psychosocial factors on the perceived and observed postoperative patient's functional recovery during the post-hospital phase and up to 12 months after hospital discharge of patients who underwent total knee or total hip arthroplasty.

METHODS

A systematic review was performed. MEDLINE, CINAHL, EMBASE and PsychINFO were systematically screened in order to find prospective longitudinal studies. Risk of bias was assessed using a modified version of a 27-item checklist for prognostic studies, as previously used by Veerbeek. A qualitative analysis was performed using the method of Zwikker.

RESULTS

A total of 26 studies, with a total of 11,020 patients, were included. In total, 22 studies were judged as having a high risk of bias. Overall, no longitudinal association with perceived or observed functional recovery was found in all of the seven preoperative psychosocial categories: A: mental well-being, B: cognitions, C: beliefs, D: expectations, E: coping, F: social support or G: personality traits in total joint arthroplasty. Mental well-being seems to be the exception in one time period (>6 weeks through ≤3 months) and change score in observed functional recovery, but only in patients awaiting total knee arthroplasty (100% and 75% of the variables were significantly and consistently associated, respectively).

CONCLUSION

Overall, the results of this systematic review suggest that there is no longitudinal association between preoperative psychosocial factors and perceived or observed patient's postoperative functional recovery after total joint arthroplasty. The psychological category mental well-being is related to observed postoperative recovery >6 weeks through ≤3 months and to change score after total knee arthroplasty.

Psychological factors as risk factors for poor hip function after total hip arthroplasty

Recovery after total hip arthroplasty (THA) is influenced by several psychological aspects, such as depression, anxiety, resilience, and personality traits. We hypothesized that preoperative depression impedes early functional outcome after THA (primary outcome measure). Additional objectives were perioperative changes in the psychological status and their influence on perioperative outcome. This observational study analyzed depression, anxiety, resilience, and personality traits in 50 patients after primary unilateral THA. Hip functionality was measured by means of the Harris Hip Score. Depression, state anxiety, and resilience were evaluated preoperatively as well as 1 and 5 weeks postoperatively. Trait anxiety and personality traits were measured once preoperatively. Patients with low depression and anxiety levels had significantly better outcomes with respect to early hip functionality. Resilience and personality traits did not relate to hip functionality. Depression and state anxiety levels significantly decreased within the 5-week stay in the acute and rehabilitation clinic, whereas resilience remained at the same level. Our study suggests that low depression and anxiety levels are positively related to early functionality after THA. Therefore, perioperative measurements of these factors seem to be useful to provide the best support for patients with risk factors.

Guided Imagery for Total Knee Replacement: A Randomized, Placebo-Controlled Pilot Study

OBJECTIVES

To determine the effect of guided imagery (GI) on functional outcomes of total knee replacement (TKR), explore psychological and neuroimmune mediators, and assess feasibility of study implementation.

DESIGN

Investigator-blinded, randomized, placebo-controlled pilot study.

SETTINGS

Hospital, surgeon's office, participant's home.

PARTICIPANTS

82 persons undergoing TKR.

INTERVENTIONS

Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments.

OUTCOME MEASURES

Gait velocity and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Function scale.

RESULTS

Outcomes for 58 participants (29 receiving GI and 29 controls) were analyzed at 6 months after surgery. The most frequent reason for noncompletion was protocol-driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint (n = 15). With imaging ability as a moderator, gait velocity, but not WOMAC Function score, was significantly improved at 6 months in the GI group. Participants in the GI group, but not the control group, had lower WOMAC Pain scores at 3 weeks after surgery than at baseline. Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group. GI group participants had lower treatment adherence but greater treatment credibility than the control group.

CONCLUSION

Randomized controlled trials of GI in the TKR population are feasible, but inclusion/exclusion criteria influence attrition. Further studies are needed to elaborate this study's findings, which suggest that guided imagery improves objective, but not patient-reported, outcomes of TKR. Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated. Further investigation into optimal content and dosing of GI is needed.

Effectiveness of psychological support in patients undergoing primary total hip or knee arthroplasty: a controlled cohort study

BACKGROUND

We hypothesised that psychological support would have a significant improvement on the mental and physical recovery of patients undergoing primary total hip or knee arthroplasty.

MATERIALS AND METHODS

200 patients were consecutively alternately assigned (1:1) to receive routine care (control group) or, in addition, psychological support from a professional psychologist (experimental group). The psychological support was provided at the pre-operative visit, during the hospitalisation period and at the rehabilitation centre.

RESULTS

Upon discharge, based on the 'Hospital Anxiety and Depression Scale, a state of anxiety was observed in 12.8 % and 78.9 % of the patients in the experimental and in the control group, respectively (p < 0.0001). A state of depression was observed in 12.8 % and 73.7 % of the patients in the experimental and in the control group, respectively (p < 0.0001). With regard to the 'Physical Component Scale' of the SF-36 questionnaire, a similar temporal trend of values was observed in the two study groups, significantly increasing over time in both groups, taking into consideration both the joint population and the two hip and knee populations separately (p < 0.0001). With regard to the 'Mental Component Scale' of the SF-36 questionnaire, in both the joint population and the two hip and knee populations separately, an exact opposite temporal trend was observed in the experimental group compared to the control group (p < 0.0001), with generally higher scores in the experimental group (p < 0.0001). In patients with hip arthroplasty, the average time to reach the physiotherapy objective (i.e., the patient ability to walk 50 metres independently and to climb 10 steps) was 6.7 ± 1.8 days (range 4-12) in the experimental group and 7.9 ± 2.2 days (range 0-13) in the control group (p = 0.0015).

CONCLUSIONS

In summary, there was a lower incidence of anxiety and depression and better mental well-being in the group of patients who received the psychological support. Within the hip arthroplasty group, the patients who received the psychological support reached the physiotherapy objective 1.2 days earlier than the patients in the control group (p = 0.0015).

LEVEL OF EVIDENCE

Level 3, Non-randomized prospective controlled cohort.

Does preoperative psychologic distress influence pain, function, and quality of life after TKA?

BACKGROUND

Preoperative psychologic distress is considered to be a risk factor for clinical dissatisfaction stemming from persistent pain and physical limitations after elective orthopaedic procedures such as lower-extremity arthroplasty. However, the degree to which psychologic distress, specifically in the form of anxiety and depression, influences surgical results has been poorly characterized.

QUESTIONS/PURPOSES

We analyzed the effect of preoperative psychologic distress on changes in pain, function, and quality of life 1 year after elective TKA.

METHODS

In this prospective cohort study, we assessed patients who underwent TKAs in 2009 and 2010. Before surgery, patients completed the Folstein Mini Mental Test, the Hospital Anxiety and Depression Scale (HAD), The Knee Society Score(©), the WOMAC quality-of-life questionnaire, and the VAS for pain. The patients were divided into two groups based on the degree of psychologic distress on the HAD Scale, and the groups were compared in terms of the above-listed clinical outcomes tools 1 year after surgery using multivariate linear models. Two hundred sixty-three patients met the inclusion criteria, and 202 (77%) completed the study protocol.

RESULTS

The presence of preoperative psychologic distress did not influence 1-year postoperative pain assessment (average reduction in pain, 40.33; 95% CI, 36.9-43.8; p = 0.18). The only factor influencing change in pain experienced by patients was the preoperative pain recorded (R(2) = 0.31; β = -0.82; p < 0.001). The patients experiencing preoperative psychologic distress obtained poorer outcomes in function (R(2) = 0.16; β = -5.62; p = 0.001) and quality of life (R(2) = 0.09; β = -0.46; p < 0.001) 1 year after receiving TKA.

CONCLUSIONS

The presence of preoperative psychologic distress is associated with worse 1-year outcomes for function and quality of life in patients undergoing TKA. Interventions designed to reduce psychologic distress may be indicated for patients to undergo this type of surgery, and incorporation of these data into discussions with patients may facilitate informed and shared decision making regarding the surgical treatment of knee osteoarthritis.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Patient's personality predicts recovery after total knee arthroplasty: a retrospective study

BACKGROUND

Increasing attention to psychological determinants may be useful in identifying patients undergoing total knee arthroplasty who may be at risk for poor postoperative outcome. However, little is known about the relationship between personality as a comprehensive reflection of stable psychological states and outcome after total knee arthroplasty. The purpose of this study was to describe the relationship between patients' diverse personalities and clinical outcomes.

METHODS

We recruited 387 patients undergoing primary total knee arthroplasty to complete the Eysenck Personality Questionnaire (EPQ) and collected demographic information before surgery. Prior to and 6 months after surgery, we used two validated functional instruments to assess satisfaction rate-the Short Form Health Survey of 36 questions (SF-36), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

Neuroticism, especially the classic type, tended to be displayed more frequently by women and younger patients. A statistically significant positive relationship was seen between outcome scores and extraversion levels in rating scales; there was a negative relationship between outcome scores especially from the SF-36 Mental Component Summary (MCS), WOMAC pain scores, and neuroticism subscales scores. Among four types of personality, sanguine patients displayed the best clinical outcomes and melancholic patients the worst. Despite good clinical outcomes, including in pain relief and functional improvement for choleric patients, satisfaction rate was unexpectedly the lowest.

CONCLUSIONS

Our results may help clinicians identify patients at risk for poor postoperative clinical outcomes and thus proceed with better communication with patients. Also, our results may indicate conducting individual attention during the perioperative period based on patient personality determined according to the EPQ in order to help attain better recovery.

The Influence of Mood on the Relation between Proactive Coping and Rehabilitation Outcomes

Cette étude a examiné un échantillon de 228 personnes âgées en réhabilitation après chirurgie pour remplacement d’une articulation; elle a porté sur la relation entre une adaptation proactive, l’humeur et les résultats psychologiques et fonctionnels. Faire face proactivement c’est une façon de réagir qui est axée sur les objectifs et nécessite qu’on affront les facteurs qui incitent le stress comme un défi plutôt qu’une menace. Selon notre hypothèse, les personnes âgées qui adoptent des stratégies proactives d’adaptation subiraient une amélioration du fonctionnement physique et psychologique apres la réadaptation et connaîtraient une humeur positive. Le modèle proposé a trouvé du support, par lequel une expérience de vigueur a été trouvé à la médiation de l’effet d’une adaptation proactive sur les résultats. Les implications théoriques et pratiques des résultats de recherche sont discutées dans le contexte des interventions qui encourageraient les personnes âgées à faire face proactivement.

Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review

OBJECTIVES

Recently, numerous studies have reported that psychological factors can influence the outcome of total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, a systematic overview is missing. The objective of this study was to examine which psychological factors influence the outcome of TKA and THA and to what extent.

METHODS

Data were obtained from the MEDLINE and EMBASE databases from inception to January 2011. Search terms included TKA and THA, outcome measures, and psychological aspects. Two reviewers independently selected the studies. Studies with a prospective before-after design with a minimum follow-up time of 6 weeks were included. One reviewer extracted the results and 2 reviewers independently conducted quality assessment. We distinguished between follow-up shorter and equal or longer than 1 year.

RESULTS

Thirty-five of 1837 studies met the inclusion criteria and were included in this systematic review. In follow-ups shorter than 1 year, and for knee patients only, strong evidence was found that patients with pain catastrophizing reported more pain postoperatively. Furthermore, strong evidence was found that preoperative depression had no influence on postoperative functioning. In long-term follow-up, 1 year after TKA, strong evidence was found that lower preoperative mental health (measures with the SF-12 or SF-36) was associated with lower scores on function and pain. For THA, only limited, conflicting, or no evidence was found.

CONCLUSIONS

Low preoperative mental health and pain catastrophizing have an influence on outcome after TKA. With regard to the influence of other psychological factors and for hip patients, only limited, conflicting, or no evidence was found.

Physical Activity, Social Support, and Family Structure as Determinants of Mood Among European-American and African-American Women

The literature indicates that mood is an important predictor of physical and psychological well-being. Mood influences a person's health perceptions, treatment compliance, and recovery. Given the importance of mood as an outcome, it is important to identify predictors of mood. The current study examined physical activity, social support, and family structure as determinants of mood among women who had recently begun a walking program. Two hundred and fifty-nine European-American and African-American women between the ages of 30 and 60 participated in the study. A significant positive relation was found between physical activity, social support, and mood, while a negative relation was found between number of children and mood. Hierarchical regression revealed that physical activity, social support of friends, mari- tal status, and number of children were significant predictors of women's mood. Race moderated the relation between number of children and mood. This study suggests that physical activity, social support, and family may be important factors in the psychological well-being of women.

A systematic review and meta-analysis of the incidence and severity of postoperative fatigue

OBJECTIVE

Postoperative fatigue is common following major abdominal surgery. Less is known about its prevalence in other surgical subgroups, and about its long-term prognosis. A systematic review of prospective cohort studies was conducted to clarify these issues.

METHOD

Studies were identified from an extensive literature search. Overall estimates of pre- to postoperative change in fatigue severity and the incidence of clinically significant postoperative fatigue were calculated using meta-analyses.

RESULTS

Eighty-one cohorts were identified. Type of surgery was found to be a possible predictor of fatigue severity, with major abdominal, gynaecological, cardiac and minor surgery apparently associated with greater fatigue than orthopaedic surgery. Limited data were available regarding the long-term persistence of postoperative fatigue.

CONCLUSION

Postoperative fatigue appears to be an important problem following only certain forms of surgery. Why this is so remains unclear, and further work using better fatigue questionnaires is now required to confirm these differences.