Systematic review: preoperative psychological factors and total hip arthroplasty outcomes

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of mental health conditions on clinical and functional outcomes after shoulder arthroplasty: a systematic review

Background

Shoulder arthroplasty (SA) has been shown to improve quality of life, though outcomes may vary between individuals. Multiple factors may affect outcomes, including preoperative mental health conditions (MHCs). The goal of this systematic review was to evaluate the clinical and functional outcomes after SA in patients with MHC compared to patients without MHC.

Methods

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines outlined by Cochrane Collaboration. A search of PubMed, the Medline Library, and EMBASE was conducted from inception until September 2023 to obtain studies reporting outcomes after total shoulder arthroplasty and reverse total shoulder arthroplasty in patients with and without MHC. Study characteristics and information on clinical and functional outcomes were collected. All included studies were case-control studies. The methodological quality of the included primary studies was appraised using the methodological index for nonrandomized studies scoring.

Results

Eleven articles published between 2016 and 2023 met inclusion criteria. In total, 49,187 patients, 49,289 shoulders, and five different MHC were included. 8134 patients in the cohort had a diagnosed MHC. The mean patient age was 67.8 years (range, 63.5-71.6 years), and 52.6% of the patients were female. The mean follow-up time was 35.5 months (range, 16.2-58.3 months). Reverse total shoulder arthroplasty was the most common type of procedure (25,543 shoulders, 51.8%). Depression and anxiety were the most reported psychiatric diagnoses (7990 patients, 98.2%). Patients with versus without MHC reported mean improvements of 38 and 42 in American Shoulder and Elbow Surgeons shoulder score and mean Visual Analog Scale pain improvements of 4.7 and 4.9, respectively. Mean complication rates of 31.4% and 14.2% were observed in patients with versus without MHC, respectively. The most prevalent surgical complication in patients with MHC was infection (1.8%), followed by prosthetic complication (1.7%), and adhesive capsulitis (1.6%).

Conclusions

Patients with MHC may have lower preoperative range of motion, worse postoperative shoulder function, and higher postoperative pain levels than patients without MHC. Patients with MHC demonstrated improvements in range of motion and functional outcomes after SA but had higher reported complication and revision rates when compared to patients without MHC. Depression and anxiety were the leading conditions correlated with lower outcomes in patients with MHC after SA. Preoperative physical therapy, mental health counseling, and expectation setting may help these patients reach the maximal achievable benefit from SA.

Identification of Presurgical Risk Factors for the Development of Chronic Postsurgical Pain in Adults: A Comprehensive Umbrella Review

Purpose

Risk factors for the development of chronic postsurgical pain (CPSP) have been reported in primary studies and an increasing number of reviews. The objective of this umbrella review was to compile and understand the published presurgical risk factors associated with the development of CPSP for various surgery types.

Methods

Six databases were searched from January 2000 to June 2023 to identify meta-analyses, scoping studies, and systematic reviews investigating presurgical CPSP predictors in adult patients. Articles were screened by title/abstract and subsequently by full text by two independent reviewers. The selected papers were appraised for their scientific quality and validity. Data were extracted and descriptively analyzed.

Results

Of the 2344 retrieved articles, 36 reviews were selected for in-depth scrutiny. The number of primary studies in these reviews ranged from 4 to 317. The surgery types assessed were arthroplasty (n = 13), spine surgery (n = 8), breast surgery (n = 4), shoulder surgery (n = 2), thoracic surgery (n = 2), and carpal tunnel syndrome (n = 1). One review included a range of orthopedic surgeries; six reviews included a variety of surgeries. A total of 39 presurgical risk factors were identified, some of which shared the same defining tool. Risk factors were themed into six broad categories: psychological, pain-related, health-related, social/lifestyle-related, demographic, and genetic. The strength of evidence for risk factors was inconsistent across different reviews and, in some cases, conflicting. A consistently high level of evidence was found for preoperative pain, depression, anxiety, and pain catastrophizing.

Conclusion

This umbrella review identified a large number of presurgical risk factors which have been suggested to be associated with the development of CPSP after various surgeries. The identification of presurgical risk factors is crucial for the development of screening tools to predict CPSP. Our findings will aid in designing screening tools to better identify patients at risk of developing CPSP and inform strategies for prevention and treatment.

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

PURPOSE

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

DESIGN

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Defining the minimum clinically important difference (MCID) in the hospital anxiety and depression scale (HADS) in patients undergoing total hip and knee arthroplasty

INTRODUCTION

Total hip (THA) and knee (TKA) arthroplasty are effective procedures, but whose success depends on various factors, including patients' genetics, sociocultural environments, and psychological factors. Patient-reported outcome measures (PROMs) provide objective health status outcomes measurements, whose lowest significant variation is detected by the minimum clinically important difference (MCID).

HYPOTHESIS

We aimed to find the MCID scores for the Hospital Anxiety and Depression Scale (HADS), HADS-A, and HADS-D in a cohort of individuals undergoing THA or TKA.

PATIENTS AND METHODS

We enrolled 88 patients suffering from osteoarthritis (43 undergoing THA, and 45 TKA) by administering HADS, SF-12 and WOMAC at baseline and then with a 12-month prospective follow-up. The MCID for HADS, HADS-A, and HADS-D was calculated using the distribution-based approach, according to various techniques (0.5 standard deviation [0.5 SD]), the standard error of measurement (SEM), the effect size (ES), and the minimum detectable change (MDC).

RESULTS

The analysis of HADS, HADS-A, and HADS-D scores revealed clinically significant improvements in symptoms in patients who underwent THA and TKA. The MCID range values were determined to be between 2.7-8.5 for the HADS, 1.4-4.4 for the HADS-A, and 1.5-4.8 for the HADS-D in the group of patients undergoing THA, and 2.1-6.7 for the HADS, 1.2-3.8 for the HADS-A, and 1.1-3.6 for the HADS-D in the TKA group.

DISCUSSION

The study determined significant improvement in all scores applying MCID analysis, which can aid physicians in interpreting anxiety and depression scores and developing both preoperative and postoperative procedures to enhance outcomes for patients undergoing THA and TKA.

LEVEL OF EVIDENCE

I; well-designed cohort study.

Utilization of patient-reported outcomes in joint replacement care design

Analysis finds health disparities among the elective surgery population.

Mental health disorders and pain modulation in orthopedic shoulder patients

Background

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

Methods

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

Results

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

Conclusion

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

Effect of White Noise Intervention Combined with Multi-dimensional Nursing Mode on Sleep Quality and Incidence of Nosocomial Infection in Patients Undergoing Hip Replacement

Objective

To investigate the clinical effects of white noise intervention combined with multi-dimensional nursing mode in patients receiving hip replacement (HR).

Methods

The study selected the clinical data of 161 patients who underwent HR in our hospital from February 2020 to February 2022 for retrospective analysis. According to patients' willingness, they were divided into the study group (n = 77, receiving white noise intervention combined with multi-dimensional nursing mode) and the control group (n = 84, receiving routine nursing). Pittsburgh sleep quality index (PSQI) scale was used to evaluate patients' sleep quality in the two groups, and the incidence of nosocomial infection in the both groups was counted.

Results

Before nursing and white noise intervention, the PSQI scores of patients' sleep quality in the two groups were all lower, with no obvious difference (P > 0.05). After nursing and white noise intervention, the sleep quality of the two groups was all improved, and the study group had overtly lower PSQI score and score of psychological status than the control group (P < 0.05). After nursing and white noise intervention, the study group had remarkably lower incidence of nosocomial infection than the control group (p < 0.05).

Conclusion

White noise intervention combined with multi-dimensional nursing mode can effectively improve the sleep quality of patients undergoing HR and reduce the incidence of nosocomial infection, which is of positive significance for promoting the recovery of postoperative limb function.

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.

Rationale for Colonic Pre-Habilitation Prior to Restoration of Gastrointestinal Continuity

The emergence of the gut microbiome as a complex ecosystem that plays a key role in human heath and disease has touched virtually every aspect of medical and surgical care. With the advent of next-generation technology to interrogate the microbiome at the level of its membership, community structure and production of metabolites, applying measures by which the gut microbiome can be manipulated to the advantage of both the patient and provider is now possible. Among the many proposed methods, the most practical and promising is dietary pre-habilitation of the gut microbiome prior to high-risk anastomotic surgery. In this review, we will outline the scientific rationale and molecular underpinning that support dietary pre-habilitation as a practical and deliverable method to prevent complications after high-risk anastomotic surgery.