Depression and anxiety after total joint replacement among older adults: a meta-analysis

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.

Opioid-Related Genetic Polymorphisms of Cytochrome P450 Enzymes after Total Joint Arthroplasty: A Focus on Drug-Drug-Gene Interaction with Commonly Coprescribed Medications

Pharmacogenomic testing, together with the early detection of drug-drug-gene interactions (DDGI) before initiating opioids, can improve the selection of dosage and reduce the risk of adverse drug interactions and therapeutic failures following Total Joint Arthroplasty. The variants of CYP genes can mediate DDGI. Orthopedic surgeons should become familiar with the genetic aspect of opioid use and abuse, as well as the influence of the patient genetic makeup in opioid selection and response, and polymorphic variants in pain modulation.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Level III, retrospective study.

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

Background

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

Methods

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

Results

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

Conclusions

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

Impact of Depressive Symptomology on Pain and Function during Recovery after Total Joint Arthroplasty

OBJECTIVES

To determine the effect of preoperative depressive symptoms on patient-reported function and pain following total joint arthroplasty (TJA) after controlling for potential confounding factors; how depressive symptoms changed after TJA; and the impact of postoperative depressive symptoms on recovery.

METHODS

A prospective cohort study undertaken in a metropolitan region in Canada enrolled 710 participants; 622 (87%) had complete 6-month data. Participants completed standardized measures preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was Western Ontario McMaster Osteoarthritis Index (WOMAC) pain and function. Three groups were created: depressive symptoms absent (n = 573, 82%), possible depressive symptoms (n = 58, 8%), and probable depressive symptoms (n = 68, 10%) using the Center for Epidemiologic Scale for Depression score. Risk-adjusted analyses examined the association between WOMAC change and the preoperative Center for Epidemiologic Scale for Depression score.

RESULTS

After risk adjustment, preoperative possible and probable depressive symptomology was associated with postoperative WOMAC pain scores that were 7.6 and 11.7 points, respectively, worse and WOMAC function scores that were 8.8 and 14.3 points, respectively, worse than those without preoperative depressive symptoms. Depressive symptoms improved postoperatively; by 6 months post-TJA, only 34 (5%) participants screened as having probable depressive symptoms, whereas only 13(2%) had possible depressive symptoms. Postoperative WOMAC pain and function scores improved, but they were negatively affected by possible and probable depressive symptoms.

CONCLUSIONS

Although depressive symptoms improve postoperatively, preoperative depressive symptoms, especially for those with probable depressive symptomology, may negatively affect postoperative pain and functional recovery even after risk adjustment.

The revision partial knee classification system: understanding the causative pathology and magnitude of further surgery following partial knee arthroplasty

AIMS

Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics.

METHODS

Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system.

RESULTS

Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall's W 0.97; p < 0.005), rising to 93% in round two (Kendall's W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall's W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall's W 0.92; p < 0.001).

CONCLUSION

The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It has been shown to be reliable, repeatable and pragmatic. The implications for patient care and health economics are discussed. Cite this article: Bone Jt Open 2021;2(8):638-645.

Do psychiatric disorders affect patient reported outcomes and clinical outcomes post total hip and knee arthroplasty?

Introduction:

The purpose of this study is to evaluate the role of major psychiatric illness on patient outcomes after total joint arthroplasty.

Methods:

Patients with a diagnosis of a major psychiatric disorder undergoing total joint arthroplasty were retrospectively matched one-to-one with a cohort without such a diagnosis. Major psychiatric disorder in the registry was identified by diagnosis of anxiety, mood, or a psychotic disorder. Primary outcome of interest included perioperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included EuroQol-5D, adverse events, length of stay, 30-day readmission, and discharge destination.

Results:

Total number of patients were 1828. The total hip arthroplasty (37.80 ± 17.91, p = 0.023) and the total knee arthroplasty psychiatric group (43.38 ± 18.41, p = 0.050) had significantly lower pre-operative WOMAC scores. At 3 months, the total hip arthroplasty (76.74 ± 16.94, p = 0.036) and total knee arthroplasty psychiatric group (71.09 ± 18.64, p < 0.01) again had significantly lower 3-month post-operative WOMAC score compared to the control groups. However, outcomes at 1 year were difficult to interpret, as patients with major psychiatric conditions had an extremely high loss to follow-up. Compared to the control groups, the total hip arthroplasty and total knee arthroplasty psychiatric group had an increased length of stay by 1.43 days (p < 0.01) and 0.77 days, respectively (p = 0.05). Similarly, the psychiatric groups were discharged directly home less often (total hip arthroplasty 86.9%, p = 0.024 and total knee arthroplasty 87.6%, p = 0.022) than the control groups.

Conclusion:

Patients with the diagnosis of a major psychiatric illness have an increased length of stay and are more likely to require a rehabilitation facility, compared to the control groups. Arguably, of utmost importance, there is a very high rate of loss to follow-up within the psychiatric groups. As such, we recommend these patients should be treated for their diagnosis prior to total joint arthroplasty. Furthermore, importance of clinical follow-up should be emphasized carefully.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Effect of Preoperative Modifiable Psychological and Behavioural Factors on Early Outcome Following Total Knee Arthroplasty in an Indian Population

BACKGROUND

Non-surgical factors have been found to have significant impact on outcome following Total Knee Arthroplasty (TKA). The study was conducted to know the independent effect of each of the four interacting psychological factors: anxiety, depression, pain catastrophizing and kinesiophobia on early outcome following TKA in an Indian population.

MATERIALS AND METHODS

104 consecutive patients undergoing TKA were included in the study and followed up at 6 weeks, 6 months and one year. Preoperatively, Hospital Anxiety and Depression Scale was used to diagnose and quantify anxiety and depression, pain catastrophizing and kinesiophobia were assessed using Pain Catastrophizing Scale and Tampa Scale for Kinesiophobia, respectively. Outcome was assessed on the basis of Knee Society Score and Knee Injury and Osteoarthritis Outcome Score. Regression analysis was done to know independent effect of each factor on outcome scores.

RESULTS

Nine (8.7%) patients were found to have undiagnosed psychopathology. The patients with psychopathologies were found to have significantly worse knee outcome scores on follow-up, although the rate of improvement in knee symptoms and function was not significantly different from those without psychopathology. The degree of Anxiety correlated with worse knee pain and stiffness up to 6 months while it correlated with poor knee function for a longer duration. The degree of depression and pain catastrophizing correlated with worse knee pain, stiffness and function at all visits while kinesiophobia didn't show correlation independent other factors.

CONCLUSION

Psychopathology was found to be associated poor knee outcome scores with degree of preoperative depression and pain catastrophizing as significant independent predictors as poor outcome, whereas the effect of degree of anxiety on knee pain and stiffness was found to wane over time. Kinesiophobia didn't show any independent correlation.

SUPPLEMENTARY INFORMATION

The online version of this article (10.1007/s43465-020-00325-x) contains supplementary material, which is available to authorized users.

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

OBJECTIVES

Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

STUDY DESIGN AND SETTING

Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

RESULTS

A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

CONCLUSION

PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

Patterns of Depressive Symptoms Before and After Surgery for Osteoarthritis: A Descriptive Study

Objective

To examine patterns of depressive symptoms before and over the year following osteoarthritis (OA) surgery, stratified by joint and postsurgical outcome.

Methods

Participants were hip (n = 287), knee (n = 360), and lumbar spine (n = 100) OA patients scheduled for joint replacement or decompression surgery with or without fusion. One pre‐ and 4 postsurgery questionnaires were completed. Depressive symptoms were quantified using the Hospital Anxiety and Depression Scale (HADS). One‐year outcomes were based on Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores for hip and knee patients and Oswestry Disability Index (ODI) scores for spine patients and were categorized as “worse” (top score tertile) vs. “better” outcomes (first, second tertiles). Plots over time were generated by joint and outcome: 1) mean pain/disability and depression scores and 2) percentage of patients meeting HADS cut‐off for depression “caseness,” reporting depression diagnosis and treatment.

Results

There were notable decreases in depression scores for patients with better outcomes. For those with worse outcomes, decreases were smaller for hip patients and were not significant for knee and spine patients. Among those with poorer outcomes, 25% of spine and knee patients were depression “cases” pre‐ and postsurgery; an additional 16% of spine and 10% of knee patients developed new “caseness” postsurgery. The proportion of these patients deemed depression cases by score was much higher than the proportion reporting diagnosis/treatment.

Conclusion

Although depressive symptoms decrease overall in OA patients postsurgery, degrees of change vary by joint and surgical outcome. Greater attention to mental health postsurgery is warranted and may lead to improved surgical outcomes, particularly among knee and spine patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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