Functional improvement in hip pathology is related to improvement in anxiety, depression, and pain catastrophizing: an intricate link between physical and mental well-being

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression

BACKGROUND

Few studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs.

METHODS

A nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant.

RESULTS

Patients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening.

CONCLUSIONS

Preoperative screening was associated with improved outcomes in depression patients.

LEVEL OF EVIDENCE

III.

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.

Association Between Symptoms of Anxiety and Depression, Hip Pathology, and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

In patients with femoroacetabular impingement (FAI), mental health has been implicated in both symptom severity and postoperative outcomes. However, there are limited data regarding the independent influences of baseline mental health and hip pathology on patient-reported outcomes over time after hip arthroscopy.

PURPOSE

To evaluate the association between mental health and structural hip pathology with pain, hip function, and quality of life (QOL).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patient records from a single surgeon's hip outcomes registry were retrospectively reviewed. Mental health was evaluated using the Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores. Pain was evaluated with the Single Assessment Numeric Evaluation score for Activities of Daily Living (SANE-ADL), while hip-related QOL was evaluated with the 12-item International Hip Outcome Tool (iHOT-12). Hip function was assessed with the Hip Outcome Score (HOS) Sport-Specific (SS) and ADL subscales. Separate mixed models were used to predict pain, QOL, and hip function, including hip pathology measures (size of labral tear, grade of chondral damage, preoperative alpha angle), anxiety, depression, and time as fixed effects and individuals as a random effect.

RESULTS

A total of 312 patients were included in this study. The preoperative alpha angle, degree of intraoperative cartilage damage, and size of the labral tear were not associated with pain or QOL (P > .05 for all). However, higher levels of anxiety and depression were significantly associated with lower SANE-ADL scores (estimate ± SE) (anxiety: -0.59 ± 0.07, P < .0001; depression: -0.64 ± 0.08, P < .0001), iHOT-12 scores (anxiety: -0.72 ± 0.07, P < .0001; depression: -0.72 ± 0.08, P < .0001), HOS-SS scores (anxiety: -0.68 ± 0.09, P < .0001; depression: -0.57 ± 0.10, P < .0001), and HOS-ADL scores (anxiety: -0.43 ± 0.05, P < .0001; depression: -0.43 ± 0.06, P < .0001).

CONCLUSION

Patients had similar improvements in pain scores, QOL, and hip function after hip arthroscopy for FAI irrespective of their degree of hip pathology. Additionally, preoperative symptoms of anxiety and depression symptoms were associated with greater pain, decreased QOL, and worse hip function both pre- and postoperatively, independent of the degree of hip pathology. This suggests that efforts to directly address symptoms of anxiety and depression may improve outcomes after hip arthroscopy.

Nanotechnology for Pain Management

Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.

Clinical Presentation Differences Among Four Subtypes of Femoroacetabular Impingement: A Case-Control Study

OBJECTIVE

The aims of this study were to assess the psychological, functional, and physical differences between patients with femoroacetabular impingement (FAI) syndrome and individuals who were asymptomatic (controls) to analyze clinical differences among 4 subtypes of FAI (cam type, cam type with labral tear, pincer type, and pincer type with labral tear), to calculate the correlations among the variables described, and to identify risk factors contributing to the hip function variance.

METHODS

A case-control study was conducted at a hospital rehabilitation unit with a cohort of individuals who were asymptomatic (controls) and a cohort of patients with FAI. Sociodemographic characteristics, pain intensity, psychological health status, hip range of motion (RoM), hip isometric strength, and hip function were assessed.

RESULTS

A total of 69 controls and 69 patients with FAI were analyzed. Although sociodemographic characteristics were comparable between samples, poorer hip RoM, strength, and psychological health were found for the cases. FAI subtypes showed no significant pain intensity, psychological health, or RoM differences (except for hip adduction), but hip strength differed among FAI subtypes. Multiple significant correlations between psychological health, pain intensity, RoM, strength, and hip function were found. The variance values of the International Hip Outcome Tool, Hip Outcome Score (HOS) for daily living activities, and HOS for sports activities were partially explained (47.6%, 36.0%, and 21.6%, respectively) on the basis of kinesiophobia, hip strength, self-efficacy, and anxiety.

CONCLUSION

Patients with FAI showed poorer psychological health, hip RoM, and strength than individuals who were asymptomatic and had similar sociodemographic characteristics. FAI subtype influenced the patients' clinical presentations. Hip strength, kinesiophobia, anxiety, and self-efficacy should be targeted for improving hip function, as they have been demonstrated to be important contributors to hip disability.

IMPACT

This study demonstrated that pain catastrophizing, hip strength, and hip adduction differed among FAI subtypes. However, hip function and pain intensity were comparable between FAI subtypes.

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

BACKGROUND

Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care.

QUESTIONS/PURPOSES

(1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors?

METHODS

We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores.

RESULTS

Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated.

CONCLUSION

This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions.

LEVEL OF EVIDENCE

Level III, prognostic study.

Depression Scores Decrease After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To evaluate clinical depression scores and functional outcomes following arthroscopic treatment of femoroacetabular impingement syndrome in patients with elevated preoperative depressive symptoms as defined by Patient-Reported Outcomes Measurement Information System for Depression (PROMIS-D).

Methods

Patients with femoroacetabular impingement syndrome completed the PROMIS-D Computer Adaptive Test and additional patient-reported outcome (PRO) measures preoperatively and at the time of postoperative visits. Patients were categorized into preoperative clinically depressed (CD) and nonclinically depressed (NCD) groups based on preoperative PROMIS-D scores. Scores ≥55 correlate to mild clinical depression, and this cutoff was used to determine preoperative depression status. PROMIS-D scores and functional outcome scores were assessed at 6 months and a minimum of 1-year postoperatively.

Results

In total, 100 patients were included with complete PROs at a minimum of 1-year follow-up. Of those included, 21 (21%) were categorized with preoperative CD. There were no differences in demographic or radiographic variables between the preoperative CD and NCD groups. At 6 months and 12 months postoperatively, the percentage of patients in the preoperative CD group with continued depression was 33.3% and 23.8%, respectively. Overall, 1-year change in PROMIS-D score for the CD group was -9.1 versus -0.8 in the NCD group (P = .001). There was no significant difference in rates of patients achieving patient acceptable symptom state between the preoperative CD and NCD groups.

Conclusions

Patients with symptoms of preoperative CD, as defined by the PROMIS-D score, demonstrated significant improvement in depressive symptoms following hip arthroscopy. In addition, patients with CD preoperatively did not show decreased rates of achieving minimum clinically important difference or patient acceptable symptom state on postoperative PROs compared with patients with NCD.

Level of Evidence

Level IV, therapeutic case series.

Association between osteoarthritis and cardiovascular disease in elderly in Japan: an administrative claims database analysis

OBJECTIVE

To investigate whether osteoarthritis (OA) is a risk factor for cardiovascular disease (CVD); whether there are differences concerning ischaemic heart disease (IHD), congestive heart failure (CHF) and stroke; and whether there are differences between OA sites (hips, knees and hand) in predicting CVD onset.

DESIGN

Population-based matched case-control study.

SETTING

Health insurance claims data among Japanese patients.

PARTICIPANTS

Japanese patients aged ≥65 years with newly diagnosed CVD and hospitalised between January 2015 and December 2020 (cases) and age-matched and sex-matched 1:1 individuals (controls).

MAIN OUTCOME MEASURES

A conditional logistic regression model was used to estimate the adjusted ORs and their 95% CIs for CVD, IHD, CHF and stroke risk, adjusting for covariates.

RESULTS

A total of 79 296 patients were included, with respect to CVD (39 648 patients with newly diagnosed CVD and 39 648 controls). After adjustment for covariates, the exposure odds of knee OA (KOA), hip OA (HipOA) and hand OA (HandOA) for CVD were 1.192 (95% CI 1.115 to 1.274), 1.057 (95% CI 0.919 to 1.215) and 1.035 (95% CI 0.684 to 1.566), respectively, showing an association only for KOA. The exposure odds of KOA, HipOA and HandOA for IHD were 1.187 (95% CI 1.086 to 1.297), 1.078 (95% CI 0.891 to 1.306) and 1.099 (95% CI 0.677 to 1.784), respectively. The exposure odds of KOA, HipOA and HandOA for stroke were 1.221 (95% CI 1.099 to 1.356), 0.918 (95% CI 0.723 to 1.165) and 1.169 (95% CI 0.635 to 2.151), respectively. Similar to CVD, only KOA was associated with both. For CHF, neither KOA nor HipOA and HandOA were associated with CHF development.

CONCLUSION

This study confirms the association of KOA with CVD, particularly IHD and stroke, in the Japanese population. The finding that patients with KOA have a higher CVD risk can potentially assist in guiding future treatment strategies.

Hip Preservation Surgery in Patients With Femoroacetabular Impingement Syndrome and Acetabular Dysplasia Improves Functional Measures and Pain Catastrophizing

Background Chronic hip pain is a debilitating condition that severely reduces one's quality of life. Prior studies uncovered a link between hip pathologies and pain catastrophizing, anxiety, and depression. The purpose of this study was to investigate whether hip preservation surgery in patients with femoroacetabular impingement syndrome (FAIS) and acetabular dysplasia (AD) improves functional outcomes and pain catastrophizing. Methods Patients with FAIS and AD were requested to complete a hip questionnaire both preoperatively and postoperatively at a single academic center (University of Texas Southwestern Medical Center, Dallas, Texas, USA). Pain catastrophizing was evaluated using the pain catastrophizing scale, and pain level was assessed using the visual analog scale. Assessments of hip functional outcomes included the hip outcome score (HOS) and the hip disability and osteoarthritis outcome score (HOOS). Outcome measures before and after treatment were compared using the dependent samples t-test. A correlation analysis, using the Spearman partial correlation coefficient (rs), was conducted to evaluate the relationship between variables. Results The results indicated a clinically significant improvement in functional measures and pain catastrophizing in patients who underwent hip preservation surgery. The most significant discovery was an inverse relationship between both HOOS quality of life (rs=-0.293, p=0.0065, false discovery rate (FDR)=0.0210) and HOS activities of daily living (rs=-0.242, p=0.0254, FDR=0.0423) and pain catastrophizing; however, similar improvements were seen in pain catastrophizing with improvements in other functional outcomes. Conclusion Undergoing hip preservation surgery for patients with AD or FAIS improved their hip functional measures and decreased pain catastrophizing postoperatively. The improvement of hip function, quality of life, and pain catastrophizing reveals an intricate link between the functional outcomes of hip preservation surgery and pain catastrophizing.

Sclareol exerts synergistic antidepressant effects with quercetin and caffeine, possibly suppressing GABAergic transmission in chicks

This study evaluated the effects of sclareol (SCL) with or without caffeine (CAF) and quercetin (QUR) using in-vivo and in-silico studies. For this, 5-day-old chicks weighing between 45 and 48 g were randomly divided into five groups and treated accordingly. The chicks were monitored to compare the occurrence, latency, and duration of sleep as well as the loss and gain of righting reflex in response to SCL-10 mg/kg, CAF-10 mg/kg, and QUR-50 mg/kg using a thiopental sodium (TS)-induced sleeping model. Data were analyzed by one-way ANOVA followed by t-Student-Newman-Keuls' as a posthoc test at 95% confidence intervals with multiple comparisons. An in-silico study was also performed to investigate the possible antidepressant mechanisms of the test and/or standard drugs with different subunits of GABAA receptors. In comparison to the SCL, CAF, and QUR individual groups, SCL+CAF+QUR significantly increased the latency while decreasing the length of sleep. The incidence of loss and gain of the righting reflex was also modulated in the combination group. SCL showed better interaction with GABAA (α2 and α5) subunits than QUR with α2, α3, and α5. All these compounds showed stronger interactions with the GABAA receptor subunits than the standard CAF. Taken together, SCL, CAF, and QUR reduced the TS-induced righting reflex and sleeping time in the combination group more than in the individual treatments. SCL may show its antidepressant effects, possibly through interactions with GABAA receptor subunits.

Pain Catastrophizing, Kinesiophobia, Stress, Depression, and Poor Resiliency Are Associated With Pain and Dysfunction in the Hip Preservation Population

Background

Psychiatric disorders are known to have a negative impact on outcomes attained from hip-preservation surgery. Psychosocial traits such as resiliency and pain avoidance likely also affect treatment outcomes, however these characteristics are less easily identified, and data is lacking supporting their presence and impact on related outcomes within the hip preservation population. We therefore evaluated hip preservation patients for a variety of maladaptive psychosocial traits and assessed patient-reported outcomes (PROs) in order to ascertain which specific traits were most associated with hip pain and dysfunction.

Methods

62 subjects aged 15-49 years presenting for evaluation of a nonarthritic hip condition completed psychosocial questionnaires and patient reported outcome measures via electronic survey as listed in table one. Participants were tested again eight weeks later to evaluate the relationship between changes in physical function, pain, and mental health behaviors. Pearson correlation coefficients assessed association between hip PROs and psychosocial tests and analyses were corrected for multiple comparisons.

Results

Pain Catastrophizing (PCS), Kinesiophobia (TSK), Stress, and PROMIS-Global Mental Health (GMH) scores correlated with poor physical function and high pain scores at zero and eight weeks. Low resiliency (BRS) and depression were also associated with elevated pain on PRO tests as well as HOOS-Physical Function. There was a moderately strong correlation between improvement in PROMIS-Physical Function (PF) from zero to eight weeks and subjects initial scores for kinesiophobia, anxiety, and stress (r= -0.45, -0.41, -0.44, all p<0.05).

Conclusion

PCS, TSK, Stress, Depression, and low BRS are associated with pain and disability in hip preservation subjects. Elevated TSK, Anxiety and Stress may be predictors of failure to improve with nonoperative treatment. These psychosocial characteristics should be investigated further as predictors of clinical outcomes in the hip preservation population. Level of Evidence: II.

Patient-Reported Outcome Measurement in Orthopaedic Trauma

Patient-reported outcome (PRO) measurements are validated tools developed to quantify self-reported aspects of capability, mindset, and circumstances in a standardized fashion. While PRO measurements have primarily been used in the research realm, a growing body of work now underscores substantial opportunities in applying the data generated by these tools to advance patient-centered musculoskeletal care. Specifically, the insights into a patient's health status derived from these measures can augment the standard biomedical approach to the management of patients with orthopaedic trauma. For instance, PRO measures have demonstrated the high prevalence of psychological distress and social concerns within trauma populations and shown that mindsets and circumstances account for a substantial amount of the variation in levels of symptom intensity and capability in these patients. Such findings support the need for a more integrated, biopsychosocial, and multidisciplinary team-based approach to orthopaedic trauma care that include both technical and nontechnical skillsets. In this chapter, we explore the range of available fixed-scale and computer adaptive PRO measures that can quantify aspects of capability, mindsets, and circumstances of the patient with orthopaedic trauma during their experience of injury, recovery, and rehabilitation. Furthermore, we define human, technical, and system-level challenges within the often complex, dynamic, and clinically intense trauma setting. Finally, we highlight potential opportunities through successfully implementing PRO measurements for clinical decision support, shared decision making, predicting health outcomes, and developing advanced care pathways for patients and populations with orthopaedic trauma.

Does Surgical Treatment Affect the Degree of Anxiety or Depression in Patients With Degenerative Cervical Myelopathy?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Preoperative mental state has been reported as one of the factors affecting the surgical outcomes of spine surgery, but few studies have examined in detail how patients' mental state is affected by spine surgery. The purpose of this study was to investigate using the Hospital Anxiety and Depression Scale (HADS) whether surgery improves preoperative depression and anxiety in patients with degenerative cervical myelopathy.

METHODS

We investigated patient-reported outcomes (Mental Component Summary, Physical Component Summary of SF-12 Health Survey, and EQ-5D, Neck Disability Index, JOACMEQ, satisfaction with treatment) and HADS one year after surgery, comparing them before and after surgery between April 2017 and February 2020. Among the cases diagnosed as preoperative anxiety and depression, we additionally compared the patient-reported outcomes based on the presence or absence of postoperative improvement in mental state, having also investigated the correlation between patient-reported outcomes and HADS for sub-analysis.

RESULTS

Among the 99 patients eligible for inclusion in the present study, we found that patient-reported outcomes and the HADS scores improved significantly after surgery. There was a moderate correlation between the amount of change in HADS-D score before and after surgery and the amount of change in NDI (moderate, r = .41), NRS of neck (moderate, r = .46), and JOACMEQ (cervical spine function; moderate, r = .43, upper extremity function; moderate, r = .41, QOL; moderate, r = .41).

CONCLUSIONS

We found that surgical treatment for patients with degenerative cervical myelopathy may improve postoperative anxiety and depression as well as other patient-reported outcomes.

Psychological Factors as Risk Contributors for Poor Hip Function after Periacetabular Osteotomy

Psychologic comorbidities have been identified as risk factors for poor outcomes in orthopedic procedures, but their influence on the outcome of hip-preserving periacetabular osteotomy (PAO) remains uncertain. This retrospective cohort study aimed to assess the impact of patients' psychological health on the outcome of PAO in patients with hip dysplasia (HD) and acetabular retroversion (AR). The study included 110 patients undergoing PAO for HD or AR between 2019 and 2021. Standardized questionnaires were administered to assess psychological factors, postoperative hip function, and activity level (mean follow-up: 25 months). Linear regression analyses were used to examine the associations between psychological factors and postoperative hip function and activity level. Both HD and AR patients showed improved postoperative hip function and activity levels. Linear regression analyses revealed that depression significantly impaired postoperative outcomes in both groups, whereas somatization negatively influenced the outcome in AR patients. General health perceptions significantly contributed to an improved postoperative outcome. These findings highlight the importance of concomitantly addressing psychologically relevant factors in order to improve patient outcomes after PAO procedures. Future prospective studies should continue to investigate the impact of various psychological factors and explore possibilities of incorporating psychological support into routine postoperative care for these patient cohorts.

Poor mental health scores correlate with inferior outcomes following minimally invasive transforaminal lumbar interbody fusion

BACKGROUND

Limited spine literature has studied the strength of association of mental health with other outcomes at time of survey collection. We aim to evaluate the degree to which mental health correlates with outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) at several postoperative periods.

METHODS

Patients having undergone elective MIS-TLIF were searched within a retrospective single-surgeon database. Five hundred eighty-five patients were included. Patient-reported outcomes (PROs) including Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), 12-item Short Form Physical Component Score (SF-12 PCS) and Mental Component Score (SF-12 MCS), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) back and leg pain, and Oswestry Disability Index (ODI) scores were collected preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year periods. Pearson's correlation tests were used to evaluate the association between both SF-12 MCS and PHQ-9 scores to other PROs at each period.

RESULTS

SF-12 MCS correlated with PROMIS PF (|r|= 0.308-0.531), SF-12 PCS (|r|= 0.207-0.328), VAS back (|r|= 0.279-0.474), VAS leg (|r|= 0.178-0.395), and ODI (|r|= 0.450-0.538) at all time points (P ≤ 0.021, all) except for preoperative SF-12 PCS and 1-year VAS leg. PHQ-9 correlated with PROMIS PF (|r|= 0.366-0.701), SF-12 PCS (|r|= 0.305-0.568), VAS back (|r|= 0.362-0.714), VAS leg (|r|= 0.319-0.694), and ODI (|r|= 0.613-0.784) at all periods (P < 0.001, all).

CONCLUSION

Poor mental health scores were correlated with lower physical function, elevated pain scores, and higher disability. PHQ-9 scores demonstrated stronger correlation in all relationships compared to SF-12 MCS. Optimization of patient mental health may lead to improved patient perception regarding function, pain, and disability following MIS-TLIF.

Genome-Wide Association Study and Transcriptome of Japanese Patients with Developmental Dysplasia of the Hip Demonstrates an Association with the Ferroptosis Signaling Pathway

This study examined the association between developmental dysplasia of the hip (DDH) and disease-associated loci in a Japanese cohort. A genome-wide association study (GWAS) of 238 Japanese patients with DDH and 2044 healthy individuals was performed. As a replicate, GWAS was also conducted on the UK Biobank data with 3315 cases and matched 74,038 controls. Gene set enrichment analyses (GSEAs) of both the genetics and transcriptome of DDH were performed. Transcriptome analysis of cartilage specimens from DDH-associated osteoarthritis and femoral neck fractures was performed as a control. Most of the lead variants were very low-frequency ones in the UK, and variants in the Japanese GWAS could not be replicated with the UK GWAS. We assigned DDH-related candidate variants to 42 and 81 genes from the Japanese and UK GWASs, respectively, using functional mapping and annotation. GSEA of gene ontology, disease ontology, and canonical pathways identified the most enriched pathway to be the ferroptosis signaling pathway, both in the Japanese gene set as well as the Japanese and UK merged set. Transcriptome GSEA also identified significant downregulation of genes in the ferroptosis signaling pathway. Thus, the ferroptosis signaling pathway may be associated with the pathogenic mechanism of DDH.

Comparison of Pain Catastrophic Scale and Anxiety in Patients With Boxer's Fracture and Other Types of Hand Fractures

OBJECTIVE

 The Pain Catastrophic Scale (PCS) is generally associated with high and low post-recovery satisfaction and measures the pain perception of patients in the literature. This study aims to evaluate the association of deliberate (as in a fight or anger causing punching a wall) boxer's fractures with catastrophic pain compared to accidental (as in a fall, accidental knocking it against a wall, etc.) fractures and evaluate the effect of anxiety about fracture union and functional recovery on clinical outcomes.

MATERIALS AND METHODS

 A total of 62 male patients with metacarpal fractures, 31 as a result of deliberate punching (1st group) and 31 with metacarpal fractures as a result of an accident (2nd group), who applied to the emergency department or orthopedic clinic with the diagnosis of metacarpal fracture between January 2021 and October 2022, were included in the study. All patients were selected from patients who were followed up with conservative plaster/splint. The PCS scores of the patients were evaluated comparatively with the clinical results measured after at least six weeks.

RESULTS

 The mean age of the patients was 30.8 (18-50) in the 1st group and 34.8 (18-64) in the 2nd Group, and no statistically significant difference was found (p=0.274). While the median PCS score was 10.5 (interquartile range {IQR}: 12.3) for the 1st group, the median PCS score was 17.5 (IQR: 14.5) for the 2nd group, and the PCS score was statistically significantly lower in group 1 (p=0.009). While the median Visual Analogue Scale (VAS) value was 0 (IQR: 0.3) for the 1st group, the median VAS value was 1 (IQR: 2.0) for the 2nd group, and the VAS score was statistically significantly lower in the 1st group (p<0.001). While the median 'quick disabilities of the arm, shoulder, and hand' (Q-DASH) value was 0 (IQR:2.3) for the 1st group, the median Q-DASH value was 3.4 (IQR:6.3) for the 2nd group, and the Q-DASH score was statistically significantly lower in the 1st group (p=0.001). No significant difference was observed between the 1st and 2nd groups in terms of grip strength values (p=0.815).

CONCLUSION

The etiology of patients presenting with a boxer's fracture should be well understood, and if necessary, these patients should be treated multidisciplinary, with psychiatric help. Better satisfaction can be achieved with lower results in patients whose PCS scoring system has lost its eigenvalue.

Effects of Depression, Anxiety, and Pain Catastrophizing on Total Hip Arthroplasty Patient Activity Level

BACKGROUND

Improvements in psychological factors are strongly associated with increased physical activity in the general population. The effects of depression, anxiety, and pain catastrophizing on activity level have not been thoroughly explored in patients undergoing total hip arthroplasty (THA). Mental health markedly influences patient perspectives on treatment success and quality of life. We hypothesized that improvements in screenings for depression, anxiety, and catastrophizing correlate with improvements in activity levels after THA.

METHODS

Two hundred ninety two patients (313 hips) who underwent THA with a minimum 1-year (mean 615 ± 270 days) follow-up completed preoperative and postoperative surveys containing the University of California Los Angeles (UCLA) Activity Score, Hospital Anxiety Depression Scale (HADS), Pain Catastrophizing Scale (PCS), and Depression Anxiety Stress Scale-21 (DASS). Wilcoxon signed-rank tests were performed between preoperative and postoperative times for outcome measures. Partial Spearman's rank-order correlations were performed between the change in UCLA Score and the change in HADS, PCS, and DASS.

RESULTS

There were significant improvements in UCLA Score (P value < .0001) and every subscale of PCS, HADS, and DASS (P values < .0001). Significant negative correlations existed between change in UCLA Score and change in HADS-anxiety (r_s = -0.21, P value < .001), change in HADS-depression (r_s = -0.23, P value < .001), and change in DASS-anxiety (r_s = -0.22, P value = .004) following THA. Weaker significant negative correlations existed between change in UCLA Score and change in the remaining PCS (P values = .006) and DASS-depression(P value = .037) subscales.

CONCLUSION

Improvements in patient-reported depression, anxiety, and pain catastrophizing screenings following THA were associated with increased activity levels. Patients who were screened for catastrophizing, depression, and anxiety achieved statistically and clinically meaningful improvements in symptoms following THA. Addressing patient mental health provides another avenue for holistic care of THA patients.

Digital Care Programs for Chronic Hip Pain: A Prospective Longitudinal Cohort Study

Chronic hip pain is a cause of disability worldwide. Digital interventions (DI) may promote access while providing proper management. This single-arm interventional study assesses the clinical outcomes and engagement of a completely remote multimodal DI in patients with chronic hip pain. This home-based DI consisted of exercise (with real-time biofeedback), education, and cognitive-behavioral therapy. Outcomes were calculated between baseline and program end, using latent growth curve analysis. Primary outcome was the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes were pain, intent to undergo surgery, mental health, productivity, patient engagement (exercise sessions frequency), and satisfaction. Treatment response was assessed using a 30% pain change cut-off. A completion rate of 74.2% (396/534), alongside high patient engagement (2.9 exercise sessions/week, SD 1.1) and satisfaction (8.7/10, SD 1.6) were observed. Significant improvements were observed across all HOOS sub-scales (14.7−26.8%, p < 0.05), with 66.8% treatment responders considering pain. Marked improvements were observed in surgery intent (70.1%), mental health (54%), and productivity impairment (60.5%) (all p < 0.001). The high engagement and satisfaction reported after this DI, alongside the clinical outcome improvement, support the potential of remote care in the management of chronic hip conditions.

Functional Outcomes of a Musculoskeletal Integrated Practice Providing Comprehensive Whole Person Care for Hip Osteoarthritis

BACKGROUND

Outcomes of hip osteoarthritis (OA) management within integrated practice units (IPUs) are lacking. This study reports 6-month and 1-year patient-reported outcomes (PROs) of IPU care, the proportion of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) at 1 year, and baseline factors associated with the likelihood of achieving MCID and SCB.

METHODS

We retrospectively evaluated 1009 new patients presenting to an IPU with hip OA between October 2017 and June 2020. Patients experienced multidisciplinary team-based management. Individuals with baseline and 6-month PROs or baseline and 1-year PROs (Hip Disability and Osteoarthritis Outcome Score Joint Replacement, HOOS JR) were included. We used anchor-based MCID and SCB thresholds and multivariable binary logistic regression models to identify baseline factors associated with achieving 1-year MCID and SCB.

RESULTS

HOOS JR increased from baseline to 6 months (Δ = 19.1 ± 2.1, P = .065) and baseline to 1 year (Δ = 35.8 ± 2.9, P < .001). At 1 year, 72.7% (IPU only) and 88% (IPU-based total hip arthroplasty [THA]) achieved MCID (P < .001), and 62.3% (IPU only) and 88% (IPU-based THA) achieved SCB (P < .001). In multivariable regression, lower baseline HOOS JR scores (r = 0.96, P = .04), undergoing THA (r = 0.213, P < .001), and fewer symptoms of generalized anxiety (r = 0.932, P = .018) were independently associated with achieving MCID at 1 year. The same factors were independently associated with achieving SCB at 1 year. Lower baseline anxiety (Generalized Anxiety Disorder Questionnaire-7 item) and greater hip-related preoperative limitations result in greater likelihood of achieving MCID and SCB.

CONCLUSION

Significant improvements in patient outcomes can be achieved by IPUs providing comprehensive care for hip OA including the management of psychological distress. Future prospective studies should compare the outcomes of IPUs with traditional care in managing diverse patient phenotypes.

Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies

Introduction

Joint replacement surgery typically results in good clinical outcome, although some people experience suboptimal pain relief and functional improvement. Predicting surgical outcome is difficult.

Objectives

There is merit in better understanding patients' perspectives of pain and function to identify avoidable problems perceived to contribute to their outcome, to inform prognostic expectations, and to identify potential cointerventions to sit alongside surgery that might mitigate pain/functional problems. Here, we aimed to synthesise the available literature exploring perspectives of people with knee osteoarthritis about their pain and function following joint replacement.

Methods

Six electronic databases and 2 websites were searched. Two independent reviewers completed study inclusion, quality assessment, and data extraction. Data were iteratively synthesised using first-, second-, and third-order analyses.

Results

Twenty-eight studies were included. Four themes were identified; perceptions of pain and function were inseparable. Theme 1 addressed experiences of recovery after surgery, which often differed from expectations. Theme 2 described the challenges of the pain experience and its functional impact, including the difficulty navigating medication use in context of personal beliefs and perceived stigma. Theme 3 articulated the toll of ongoing problems spanning pain-function-mood, necessitating the need to "endure." Theme 4 encompassed the importance of clinical/social interactions on mood and pain, with reports of concerns dismissed and practical support missing.

Conclusions

Together, these findings show that numerous individual considerations beyond the technical aspects of surgery influence experiences of pain and function. A tailored approach addressing these considerations from the patient perspective could provide a basis for improved success of knee replacement surgery.

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.