The impacts of anxiety and depression on outcomes in orthopaedic trauma surgery: a narrative review

Introduction

The impact of anxiety and depression on outcomes in orthopaedic trauma surgery is a topic of growing research interest.

Patients and methods

Orthopaedic trauma patients often experience high rates of psychiatric disorders, with anxiety and depression being the most prevalent. Mental health disorders have been shown to increase the risk of negative surgical outcomes and morbidity. This narrative review seeks to summarize the current literature surrounding the impacts of anxiety and depression on orthopaedic trauma surgery outcomes.

Discussion

There is a bidirectional relationship between chronic pain and mental health disorders, involving overlapping brain regions and neurotransmitter pathways. Anxiety and depression have been identified as predictors of negative surgical outcomes in orthopaedic trauma patients. Screening tools like the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-7 (GAD-7), and Medical Outcomes Study 36-item Short Form (SF-36) can assess mental health status and help tailor interventions. Psychological distress, chronic pain, and traumatic limb amputation are factors that contribute to adverse mental health outcomes in orthopaedic trauma patients. Opioid use for pain management is common in orthopaedic surgery, but it can worsen symptoms of depression and lead to dependency. Non-opioid pain management strategies may improve postoperative outcomes by reducing the impact of opioid-exacerbated depression.

Conclusion

Mental health interventions, both preoperative and postoperative, are crucial in optimizing surgical outcomes and improving patient quality of life. Multidisciplinary approaches that address both physical and mental health are recommended for orthopaedic trauma patients. Further research is needed to develop effective interventions for improving mental health outcomes in this patient population.

Evaluating the Effect of Comorbidities on the Success, Risk, and Cost of Digital Replantation

PURPOSE

The clinical decision to replant an amputated digit is driven primarily by surgical indication. However, the extent to which patient comorbidity should play into this decision is less well defined. This study was designed to determine the effect of patient comorbidities on the success, risk, and cost of digital replantation.

METHODS

All amputation injuries and digital replantation procedures captured by the National Inpatient Sample during 2001 to 2012 were identified. A successful replantation procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Patient comorbidities were tested for association with failure of replantation, risk of postoperative complications, and overall hospital costs.

RESULTS

We identified 11,788 digital replantation procedures. A total of 3,604 patients (30.6%) experienced revascularization failure associated with replantation. The risk for replant failure was highest among patients with psychotic disorders, peripheral vascular disease, and electrolyte imbalances. The risk for postoperative complications was highest among patients with electrolyte imbalances, drug abuse, or chronic obstructive pulmonary disease. Hospital costs were greatest among patients with deficiency anemias, electrolyte imbalances, or psychotic disorders. Patients with more than 3 comorbidities experienced significantly higher failure, risk of postoperative complications, and cost of digital replantation.

CONCLUSIONS

These data suggest that even when surgical indications are met, patients with more than 3 comorbidities and those who have a history of alcohol abuse, deficiency anemias, electrolyte imbalances, obesity, peripheral vascular disease, or psychotic disorders are at increased risk of replantation failure and associated postoperative complications. Assessment of this risk should have a role in decision making regarding whether a digit should be replanted. Patients at high risk should be carefully counseled regarding the difficult perioperative course before undergoing digital replantation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

The Detrimental Effect of Decentralization in Digital Replantation in the United States: 15 Years of Evidence From the National Inpatient Sample

PURPOSE

Recent reports suggest a decrease in success rates in digital replantation in the United States. We hypothesize that this decrease may be associated with decentralization of replants away from high-volume hospitals.

METHODS

All amputation injuries and digital replants captured by the National Inpatient Sample during 1998 to 2012 were identified. Procedures were characterized as occurring at high-volume hospitals (> 20 replants/y), and as being performed by high-volume surgeons (> 5 replants/y). A successful procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Hospital and surgeon volume were tested for association with the year and the success of the procedure.

RESULTS

The authors identified 101,693 amputation injuries resulting in 15,822 replants. The overall success of replants dropped from 74.5% during 2004 to 2006 to 65.7% during 2010 to 2012. The percentage of replants being performed at high-volume hospitals decreased from 15.5% during 2004 to 2006 to 8.9% during 2007 to 2009. Similarly, the percentage of replants being performed by high-volume surgeons decreased from 14.4% during 1998 to 2000 to 2.6% during 2007 to 2009. Replants performed by high-volume surgeons operating at high-volume hospitals had higher success rates than low-volume surgeons operating at low-volume hospitals (92.0% vs 72.1%). In addition, high-volume surgeons operating at high-volume hospitals attempted replantation at greater rates than low-volume surgeons operating at low-volume hospitals (21.5% vs 11.0%). Overall, an amputation injury presenting to a high-volume surgeon at a high-volume center had a 2.5 times greater likelihood of obtaining a successful replantation than an amputation injury presenting to a low-volume surgeon at a low-volume hospital.

CONCLUSIONS

These data suggest that decreased success rates of digital replantation in the United States are correlated with the decentralization of digital replantation away from high-volume hospitals.

CLINICAL RELEVANCE

The establishment of regional centers for replant referral may greatly increase the success of digital replantation in the United States.