The Effect of Psychiatric Diagnosis and Psychotropic Medication on Outcomes Following Total Hip and Total Knee Arthroplasty

The Impact of Mental Health on Total Joint Arthroplasty Outcomes

Total hip and knee arthroplasty surgery are among the most successful orthopedic surgical interventions. However, there remains a cohort of patients who are dissatisfied with the outcome of their surgery despite measurable improvement in functional outcomes. Validated patient outcome measurement systems have depicted that patient mental health may influence a patient's interpretation of surgical outcome despite improvement in functional capability. Furthermore, patients who suffer from poor mental health may have a higher likelihood of postoperative complication that result in large socioeconomic burden. The ability of a surgeon to utilize patient health questionnaires to screen for and identify patients with mental health issues is important.

The Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS)-10 Global Mental Health T-Score: An Independent Predictor of Immediate Postsurgical Outcomes Following Elective Total Knee Arthroplasty

BACKGROUND

Mental illness is a known risk factor for poor postoperative outcomes following total knee arthroplasty (TKA); however, a diagnosed mental illness does not always reflect the current state of a patient's mental health. Using the preoperative Patient-Reported Outcomes Measurement Information System-10 Mental Health T-score (MHT), the purpose of this study was to understand the association between mental health and a patient's immediate inpatient recovery pattern following TKA.

METHODS

This was a retrospective study of patients undergoing elective primary TKA. Patients were grouped based on their MHT score (above average] > 50, average 40 to 50, and below average < 40). Postsurgical parameters included inpatient opioid consumption, pain reporting, functional measures, and discharge disposition.

RESULTS

A total of 2,740 patients were included in this study (above average 55.8%, average 35.4%, and below average 8.8%). Multivariate modeling demonstrated that an MHT score below 40 was an independent risk factor for opioid consumption, pain reporting, discharge disposition, ambulation distance, and timed-up-and-go performance. A diagnosed mental illness was not associated with poor outcomes.

CONCLUSIONS

The MHT can be used as a preoperative screening tool that can identify an at-risk group not previously described. An MHT < 40 was associated with poor immediate postoperative outcomes.

In-Hospital Pain Reporting Among Total Knee Arthroplasty Patients with Anxiety Diagnoses

PURPOSE

To determine the association between anxiety disorder diagnoses and in-patient opioid usage, pain perception, and discharge disposition post-total knee arthroplasty (TKA).

DESIGN

Retrospective review of elective primary TKA.

METHODS

Patients diagnosed with anxiety were assigned to the anxiety group, and those without a mental health diagnosis were assigned to the control group. Variables of interest included self-reported pain scores (at rest and with activity) collected immediately after surgery and at discharge, inpatient opioid usage, and discharge disposition.

RESULTS

A total of 4,404 patients (492 in the anxiety group) were included in the analysis. There were differences between groups in median pain scores reported immediately postoperatively at rest (anxiety group: 2, interquartile range [IQR] 0-6, control group: 0, IQR 0-5, p = .003) and with activity (anxiety group: 4, IQR 0-6, control group: 3, IQR 0-60, p = .011), at discharge at rest (anxiety group: 3, IQR 2-5, control group: 3, IQR 1-4, p < .001), and with activity (anxiety group: 5, IQR 3-6, control group: 4, IQR 2-6, p < .001). In the anxiety group, 60% of patients had opioid usage greater than the median of 61 morphine milligram equivalents while in-patient compared with 48% of patients in the control group (p < .001).

CONCLUSIONS

This study provides evidence of the complex relationships between anxiety and in-hospital outcomes in patients undergoing primary TKA.

Research Progress and Hot Topics in Telerehabilitation for Hip or Knee Arthroplasty

OBJECTIVE

Many publications on telerehabilitation for hip or knee arthroplasty have been published in recent years. However, no specific studies have attempted to characterize research hotspots, global research collaborations, or trends related to telerehabilitation after hip or knee arthroplasty. Therefore, the aim of this bibliometric analysis was to provide an overview of the current status of research and map the research landscape on telerehabilitation for joint replacement to understand current trends, identify research gaps, and guide future research directions.

METHODS

The Web of Science Core Collection and PubMed were comprehensively searched to identify all relevant English-language documents published from 2003 to June 7, 2024. Data from these published studies were then cleaned and structured. CiteSpace and VOSviewer were used to conduct the bibliometric visualization and comparative analysis of countries, institutions, journals, authors, references, and keywords. Then, the map illustrating the research hotspots and knowledge structure was plotted based on the analysis results.

RESULTS

A total of 229 records were obtained, and the number of articles published has increased steadily over the investigated period. The largest increase was observed in 2022. With the highest number of publications and centrality, the United States was the most influential country. The University of Sherbrooke was the most productive institution. Author Boissy P. ranked first in terms of the number of publications, while Tousignant M. ranked highest in cited authors, with 7 publications and 65 citations. The Journal of Arthroplasty published the greatest number of articles, with 29 publications. The most popular keywords from 2018 to 2023 were "home telerehabilitation," "older adults," and "physical therapy". In terms of the strongest citation burst, the top five keywords were associated with "total knee arthroplasty," "in home tele rehabilitation," "physical activity," "motion," and "range." The frontier keywords were "patient satisfaction," "mobile application," "self-efficacy," "fear avoidance model," "home assessment tool," and "cost benefit analysis."

CONCLUSIONS

The current status and trends in telerehabilitation for hip or knee arthroplasty are presented. A major concern at present is physical therapy for home telerehabilitation in the elderly. In the future, mobile app-based telerehabilitation programs for arthroplasty will continue to be encouraged, and some outcomes, such as "patient satisfaction," "self-efficacy," and "cost benefit analysis," are expected to receive more attention. Our work will serve as a valuable resource, providing fundamental references and a directional guide for future research.

Positive Deviance and Exploring the Role of Mental Health on Early Postoperative Recovery After Total Hip Arthroplasty: A Retrospective Analysis Using the PROMIS-10 Global Health

INTRODUCTION

Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT.

METHODS

This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition.

RESULTS

A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group.

DISCUSSION

The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT.

LEVEL OF EVIDENCE

Diagnostic study-retrospective cohort study.

Aetiology of patient dissatisfaction following primary total knee arthroplasty in the era of robotic-assisted technology

Aims

Patient dissatisfaction following primary total knee arthroplasty (TKA) with manual jig-based instruments has been reported to be as high as 30%. Robotic-assisted total knee arthroplasty (RA-TKA) has been increasingly used in an effort to improve patient outcomes, however there is a paucity of literature examining patient satisfaction after RA-TKA. This study aims to identify the incidence of patients who were not satisfied following RA-TKA and to determine factors associated with higher levels of dissatisfaction.

Methods

This was a retrospective review of 674 patients who underwent primary TKA between October 2016 and September 2020 with a minimum two-year follow-up. A five-point Likert satisfaction score was used to place patients into two groups: Group A were those who were very dissatisfied, dissatisfied, or neutral (Likert score 1 to 3) and Group B were those who were satisfied or very satisfied (Likert score 4 to 5). Patient demographic data, as well as preoperative and postoperative patient-reported outcome measures, were compared between groups.

Results

Overall, 45 patients (6.7%) were in Group A and 629 (93.3%) were in Group B. Group A (vs Group B) had a higher proportion of male sex (p = 0.008), preoperative chronic opioid use (p < 0.001), preoperative psychotropic medication use (p = 0.01), prior anterior cruciate ligament (ACL) reconstruction (p < 0.001), and preoperative symptomatic lumbar spine disease (p = 0.004). Group A was also younger (p = 0.023). Multivariate analysis revealed preoperative opioid use (p = 0.012), prior ACL reconstruction (p = 0.038), male sex (p = 0.006), and preoperative psychotropic medication use (p = 0.001) as independent predictive factors of patient dissatisfaction.

Conclusion

The use of RA-TKA demonstrated a high rate of patient satisfaction (629 of 674, 93.3%). Demographics for patients not satisfied following RA-TKA included: male sex, chronic opioid use, chronic psychotropic medication use, and prior ACL reconstruction. Patients in these groups should be identified preoperatively and educated on realistic expectations given their comorbid conditions.

Results of Primary Total Knee Arthroplasty in Patients on Chronic Psychotropic Medications

BACKGROUND

Psychotropic medications are commonly used to treat several mental health conditions. The aim of this study was to determine the impact of psychotropic medications in patients undergoing primary total knee arthroplasty (TKA) with respect to postoperative opioid use, complications, patient-reported outcome measures, and satisfaction.

METHODS

This is a retrospective cohort study of 514 consecutive patients undergoing primary TKA. There were 120 patients (23.3%) who were excluded due to preoperative opioid usage. The remaining 394 patients had a minimum 1-year follow-up. Of those, 133 (34%) were on psychotropic medications preoperatively and were compared to the remaining 261 (66%) patients who were not on psychotropics. Clinical data, satisfaction, Knee Society (KS) scores, Western Ontario McMaster Universities Arthritis Index, Patient-Reported Outcomes Measurement Index Score, Forgotten Joint Scores, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, postoperative opioid medication usage, and complications were compared.

RESULTS

The study cohort (psychotropic medications) had significantly lower postoperative KS Function, KS Knee, Forgotten Joint Scores, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario McMaster Universities Arthritis Index, and Patient-Reported Outcomes Measurement Index Score compared to the control group. The study group had a lower overall satisfaction score (Likert scale 1 to 5) and a lower percentage of patients either satisfied or very satisfied (4.55 versus 4.79, P < .001; 92.0 versus 97.24%, P = .03, respectively). Postoperative opioid usage was significantly greater in the study group at both 6.4 weeks (range, 4 to 8) and 12-month follow-up (52.76 versus 13.33%, P < .001; 5.51 versus 0.39%, P = .002, respectively). There were no differences in complications and revisions between the groups.

CONCLUSIONS

Patients on psychotropic medications should be educated on the risk of increased opioid consumption, diminished satisfaction, and patient-reported outcome measures following primary TKA. Given the large number of patients on psychotropic medications undergoing TKA, additional studies are needed to further improve clinical outcomes in this group.

Effects of Preexisting Anxiety and Depression on Postoperative Outcomes in Patients Aged 30 Years and Younger Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Background: Mental health influences postoperative outcomes in orthopedic procedures. Increasing attention is being paid to this effect. Purpose: We sought to evaluate the effect of diagnosed depression, anxiety, or both on postoperative outcomes in patients who have undergone hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Methods: We conducted a retrospective cohort study of 289 patients aged 30 years or younger who underwent hip arthroscopy for FAIS at a single institution from January 2014 to June 2021. Univariate statistics were used to assess differences between patients diagnosed with depression, anxiety, or both, and those without these diagnoses. Differences included demographics, operative characteristics, and postoperative outcomes: duration of postanesthesia care unit (PACU) stay, PACU pain scores, complications, reoperations, postoperative injections, 90-day emergency department (ED) visits, and patient-reported outcome measures (PROMs). Multivariate analysis was used to evaluate risk factors for postoperative complications, including wound infection, documented reinjury, postoperative intra-articular hip injection, and any reoperation. Results: Patients diagnosed with depression, anxiety, or both were more likely to be older, female, and have a higher comorbidity burden. At the time of surgery, they were more likely to undergo concomitant procedures, including bursectomy and iliotibial band release. Postoperatively, they had longer PACU stays (90.5 vs 75.1 minutes) and higher first PACU pain scores (5.9 vs 4.6), as well as higher rates of postoperative injection (18.1 vs 9.2%), any reoperation (13.9% vs 4.6%), and revision hip arthroscopy (11.1% vs. 3.7%). Diagnoses of depression, anxiety, or both were independently predictive of any reoperation (odds ratio [OR] = 2.841) and revision hip arthroscopy (OR = 3.401). Conclusion: This retrospective cohort study found that, in patients undergoing hip arthroscopy for FAIS, there was an association between a diagnosis of depression, anxiety, or both, and increased comorbidities, higher first PACU pain scores, longer PACU stays, and increased rates of postoperative injection, any reoperation, or revision hip arthroscopy. Targeted interventions may improve outcomes, but further study is warranted.

Efficacy and risk factors for anxiety and depression after mini-incision hip arthroplasty for femoral head osteonecrosis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a prevalent orthopedic issue, leading to the collapse and fragmentation of the femoral head in its advanced stages, which can severely impair patients' quality of life. Total hip arthroplasty (THA) is a clinical intervention frequently used to alleviate ONFH symptoms and reinstate hip functionality. The conventional surgical technique is invasive and comes with an extended recuperation period, posing significant challenges for patients. With the progression of medical technology, the use of the mini-incision technique in minimally invasive THA (MITHA) has become more prevalent. However, comparative studies examining the effectiveness of these two surgical procedures in treating ONFH remain scarce. Furthermore, understanding patients' psychological well-being is crucial given its profound influence on postoperative recuperation.

AIM

To evaluate the impact of mini-incision MITHA on ONFH treatment and to identify the risk factors associated with postoperative anxiety and depression.

METHODS

A retrospective study was conducted on 125 patients treated for ONFH at Xi'an Hong Hui Hospital between February 2020 and January 2022, with the term "consecutive" indicating that these patients were treated in an unbroken sequence without any selection. Among these, 60 patients (control group) underwent traditional THA, while 65 patients (observation group) were treated with mini-incision MITHA. Variations in the visual analog scale (VAS) score and the Harris hip score were monitored. Additionally, shifts in pre- and posttreatment Hamilton anxiety (HAMA) and Hamilton depression (HAMD) scale scores were recorded. Patients with both postoperative HAMA and HAMD scores of ≥ 8 were identified as those experiencing negative emotions. Logistic regression was utilized to analyze the determinants influencing these negative emotional outcomes. Comparative analyses of surgical and postoperative metrics between the two groups were also conducted.

RESULTS

Posttreatment results indicated a significantly higher VAS score in the control group than in the observation group, while the Harris score was considerably lower (P < 0.0001). The observation group benefited from a notably shorter operation duration, reduced blood loss, diminished incision size, and a decreased postoperative drainage time (P < 0.0001), accompanied by a reduced hospital stay and lower treatment costs (P < 0.0001). The control group had elevated posttreatment HAMA and HAMD scores in comparison to the observation group (P < 0.0001). Multivariate logistic regression revealed that being female [odds ratio (OR): 4.394, 95%CI: 1.689-11.433, P = 0.002], having a higher postoperative VAS score (OR: 5.533, 95%CI: 2.210-13.848, P < 0.0001), and having higher treatment costs (OR: 7.306, 95%CI: 2.801-19.057, P < 0.0001) were significant independent determinants influencing postoperative mood disturbances.

CONCLUSION

Compared to conventional THA, mini-incision MITHA offers advantages such as reduced operation time, minimal bleeding, and a shorter incision in ONFH patients. Moreover, factors such as sex, postoperative pain (reflected in the VAS score), and treatment costs significantly impact postoperative anxiety and depression.

What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures

BACKGROUND

Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary.

QUESTION/PURPOSE

Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA?

METHODS

The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively.

RESULTS

Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness.

CONCLUSION

Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness.

The effectiveness of a mobile application-based programme for rehabilitation after total hip or knee arthroplasty: A randomised controlled trial

BACKGROUND

Total hip arthroplasty and total knee arthroplasty are widely performed worldwide. Patients undergoing total hip or knee arthroplasty are often discharged after a short hospital stay. Using information and communication technologies, such as mobile applications, to provide rehabilitation services remotely may be a strategy to support patients' postoperative recovery.

OBJECTIVE

This study aimed to evaluate the effectiveness of a rehabilitation programme delivered via a mobile application among Chinese patients after total hip or knee arthroplasty.

DESIGN

Randomised controlled trial.

SETTING

A teaching hospital in Shanghai, China.

PARTICIPANTS

Eighty-six patients who received a unilateral primary total hip or knee arthroplasty.

METHODS

The participants were recruited in the hospital and randomised into either the experimental or control group. Once discharged from the hospital, the control group (n = 43) received usual care, and the experimental group (n = 43) received usual care plus a 6-week mobile rehabilitation programme. Outcomes were assessed three times: the day before hospital discharge and 6 and 10 weeks after discharge. Primary outcomes were the changes in scores of self-efficacy and patient-reported physical function from baseline to 6 weeks post-discharge. Secondary outcomes included changes in scores of pain, depression, anxiety, and health-related quality of life. Data were analysed using generalised estimating equations.

RESULTS

At 6 weeks after hospital discharge, the experimental group showed statistically significant improvements compared to the control in scores of self-efficacy (adjusted mean difference = 0.72, 95% CI 0.31 to 1.14, P < .001) and patient-reported physical function (adjusted mean difference = 4.57, 95% CI 1.24 to 7.90, P = .007). The between-group difference in self-efficacy probably reached clinical significance. At week-10 follow-up, the experimental group had statistically significant improvements in scores of self-efficacy (adjusted mean difference = 0.64, 95% CI 0.33 to 0.95, P < .001), health-related quality of life (adjusted mean difference = 0.06, 95% CI 0.01 to 0.10, P = .018), anxiety (adjusted mean difference = -0.51, 95% CI -0.91 to -0.10, P = .015), and depression (adjusted mean difference = -0.37, 95% CI -0.66 to -0.08, P = .012). The between-group difference in self-efficacy and health-related quality of life may be clinically significant.

CONCLUSION

Mobile application-based rehabilitation demonstrated potentially positive effects on patients' self-efficacy, patient-reported physical function, health-related quality of life, and levels of anxiety and depression.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry on 6 July 2021 (ACTRN12621000867897).

Does resilience predict hospital length of stay after total knee arthroplasty? A prospective observational cohort study

Background

Resilience, or the ability to bounce back from stress, is a key psychological factor that is associated with ongoing functional independence and higher quality of life in older adults in the context of chronic health conditions. Emerging research has explored resilience and patient-reported outcomes after TKA. Our primary aim was to explore the relationship between resilience and acute hospital length of stay after total knee arthroplasty (TKA).

Methods

A prospective observational study recruited 75 participants one month before total knee arthroplasty from two Australian hospitals. Two preoperative psychological measures were used: the Brief Resilience Scale, and for comparison, the Depression, Anxiety and Stress Scale-21 (DASS-21). We collected sociodemographic, medical and surgical details, patient-reported pain, function, fatigue and quality of life one month before TKA. Health service data describing acute hospital length of stay, inpatient rehabilitation use, and physiotherapy occasions of service were collected after TKA. Non-parametric analysis was used to determine any differences in length of stay between those with low or high resilience and DASS-21 scores. Secondary regression analysis explored the preoperative factors affecting acute hospital length of stay.

Results

No significant difference was detected in length of stay between those with a low or a high resilience score before TKA. However, the group reporting psychological symptoms as measured by the DASS-21 before TKA had a significantly longer acute hospital length of stay after TKA compared to those with no psychological symptoms [median length of stay 6 (IQR 2.5) days vs. 5 (IQR 2) days, respectively (Mann-Whitney U = 495.5, P=0.03)]. Multivariate regression analysis showed that anesthetic risk score and fatigue were significant predictors of length of stay, with the overall model demonstrating significance (χ2=12.426, df = 4, P=0.014).

Conclusions

No association was detected between the brief resilience score before TKA and acute hospital length of stay after TKA, however, symptoms on the DASS-21 were associated with longer acute hospital length of stay. Preoperative screening for psychological symptoms using the DASS-21 is useful for health services to identify those at higher risk of longer acute hospital length of stay after TKA.

Association between antidepressants, benzodiazepine and all-cause mortality in elderly hip fracture: A Korean nationwide cohort study

BACKGROUND

The purpose of this study was to analyze the association between the preoperative and postoperative use of antidepressant and benzodiazepine and all-cause mortality in elderly hip fracture patients.

METHODS

Patients who underwent surgical treatment for hip fracture over 65 years old were classified into Past-user, Current-user, and Non-users for each period according to use history for antidepressants or benzodiazepines. And, for the subgroup analysis, patients were classified by presence of past history for psychiatric medication. A multivariable-adjusted Cox proportional hazards model was used to investigate the effects of antidepressants and benzodiazepines on all-cause mortality.

RESULTS

A total of 15,576 patients were included in this study. Past users of antidepressants and benzodiazepines were 5699 (36.59%) patients and 11,319 (72.67%) patients, respectively. Current users of antidepressants and benzodiazepines were 2888 (18.54%) patients and 6287 (40.36%) patients, respectively. There were no statistically significant differences in the adjusted hazard for death compared to the non-users for both the past and the current users (p > 0.05). In the subgroup analysis, there were 12,502 once-users and 3074 never-users according to psychiatric medication. Current uses of antidepressants and benzodiazepine in the once-user did not increase adjusted hazard for death compared to the non-users (p>0.05). However, current uses of antidepressants by never-users increased the adjusted hazard for death compared to the non-user (adjusted hazard ratio, 1.31; 95% CI, 1.08-1.59; p = 0.007).

CONCLUSIONS

No association was observed between the uses of antidepressants and benzodiazepines after hip fracture and mortality risk in elderly patients who received psychiatric medication before hip fracture. However, the use of these medications was associated with increased all-cause mortality risk in patients who had no history of psychiatric medication before hip fracture.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Effects of Preexisting Depression and Anxiety on Postoperative Outcomes following Arthroscopic Rotator Cuff Repair

Background

Rotator cuff repairs (RCRs) are one of the most commonly performed shoulder surgeries in the United States. Psychological health has been shown to influence postoperative outcomes in orthopedic procedures. The purpose of this study is to evaluate the relationship between depression and anxiety (DA) and psychotropic medication and postoperative outcomes following RCR.

Methods

A single institution retrospective observational cohort study of 816 patients undergoing arthroscopic RCR from January 2014 to October 2020 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes; multivariate analysis was used to evaluate risk factors for postoperative complications.

Results

Patients with DA were more likely to have a higher first (3.60 vs. 3.00, P = .004) and last (1.23 vs. 0.96, P = .042) postoperative pain scores, lower first (18.67 vs. 21.85, P = .008) and last (61.87 vs. 64.71, P = .014) Upper Extremity Functional Score (UEFS), more likely to experience an emergency department visit postoperatively (9.1 vs. 5.0%, P = .028), have a symptomatic recurrent tear (8.2 vs. 3.3%, P = .003), and persistent pain (4.3 vs. 1.2%, P = .011). After controlling for age, sex, body mass index, American Society of Anesthesiologists score, diabetes, smoking, coronary artery disease, asthma, hypertension, psychotropic medication and DA, having DA at the time of surgery was independently predictive of any complication (odds ratio, 2.033; P = .028) and persistent pain (odds ratio, 8.232; P ≤ .001). Patients with and without DA showed significant improvement in postoperative pain and UEFS from the first to the last measurement (P < .001).

Conclusion

DA is not a deterrent for RCR but targeted interventions may be needed to decrease the occurrence of complications.

Mobile rehabilitation support versus usual care in patients after total hip or knee arthroplasty: study protocol for a randomised controlled trial

Background

The global increase in total hip or knee arthroplasty has led to concern about the provision of postoperative rehabilitation. Telerehabilitation may be a strategy to meet the patients’ requirements for rehabilitation after arthroplasty. This study aims to investigate the effectiveness of a telerehabilitation programme delivered via the mobile application WeChat in patients after total hip or knee arthroplasty on the following outcomes: self-efficacy, physical function, pain, depression, anxiety and health-related quality of life.

Methods

This is a single-centre, single-blinded, parallel-group, superiority randomised controlled trial conducted in Shanghai, China. Eighty-four eligible participants who undergo primary total hip or knee arthroplasty will be recruited preoperatively in a university teaching hospital and randomly assigned to the experimental or control group with their informed consent. Once discharged, the control group (n = 42) will receive the usual care provided by the hospital. The experimental group (n = 42) will receive usual care and a 6-week mobile application rehabilitation programme that consists of physical exercises and techniques for enhancing participants’ self-efficacy for rehabilitation. Baseline assessments will be conducted on the day before hospital discharge, and outcome assessments will be conducted 6 and 10 weeks postoperatively. The primary outcomes are changes in self-efficacy and physical function 6 weeks postoperatively, and the secondary outcomes include pain, depression, anxiety and health-related quality of life. The approach of a generalised estimating equation will be used to analyse the effect of the intervention on outcomes at a significance level of 0.05.

Discussion

This study is the first of its kind conducted in China to incorporate self-efficacy and learning theories as a framework to guide the development of a mobile application rehabilitation programme after arthroplasty. This study will contribute to the knowledge about the effectiveness of mobile application-based rehabilitation among patients after total hip or knee arthroplasty. If the findings are positive, they will support the implementation of mobile application-based rehabilitation in practice, which may potentially increase the accessibility of rehabilitation services as well as patient adherence to rehabilitation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12621000867897. Retrospectively registered on July 6, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06269-x.

Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses

Background

This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications.

Material and methods

This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms.

Results

Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (β 7.1; P < .001) and with medication (β 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (β 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001).

Conclusion

One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.

Orthopedic Patients with Mental Disorder: Literature Review on Preoperative and Postoperative Precautions

Because of the increasing global trend of patients with mental disorders, orthopedic surgeons are more likely to encounter orthopedic patients with mental disorders in clinical settings. Identifying the characteristics of these patients and implementing psychiatric management can affect the clinical outcome of orthopedic treatment. Thus, orthopedic surgeons need to assess the psychiatric medical history of orthopedic patients with mental disorders before surgery and understand the psychological and behavioral patterns of patients with mental disorders. In addition, appropriate psychiatric consultations and evaluations are necessary to prevent worsening of mental disorders before and after surgery.

Implant Malalignment may be a Risk Factor for Poor Patient-Reported Outcomes Measures (PROMs) Following Total Knee Arthroplasty (TKA)

BACKGROUND

Implant malalignment may be a risk factor for poor patient-reported outcomes measures (PROMs) following total knee arthroplasty (TKA).

METHODS

Postoperative surveys were administered to assess PROMs regarding satisfaction, pain, and function in 262 patients who underwent surgery at 4 centers in the U.S. and U.K (average age, 67.2) at a mean 5.5 years after primary TKA. Postoperative distal femoral angle (DFA), proximal tibial angle (PTA), and posterior tibial slope angle (PSA) were radiographically measured, and outliers were recorded. PROMs were compared between patients with aligned versus malaligned knees using univariate analysis.

RESULTS

Patients with DFA, PTA, and PSA outliers were more likely to experience similar or decreased activity levels postoperatively than patients with no alignment outliers, as were patients with 1 or 2 outliers of any kind (P < .05). Patients with DFA, PTA, and PSA outliers were significantly more likely to be dissatisfied with their ability to perform activities of daily living (ADLs), as were patients with 1 or 2 outliers of any kind (P < .05). Patients with DFA and PSA outliers were more likely to be dissatisfied with their degree of pain relief, as were patients with 2 outliers of any kind (P < .05). Finally, patients with DFA and PSA outliers, as well as those with 1 outlier of any kind, were more likely to be dissatisfied with their overall knee function (P < .05).

CONCLUSION

DFA, PTA, and PSA outliers represent a significant risk factor for decreased satisfaction with activities of daily living(ADLs), pain relief, and knee function, as well as decreased activity levels.

LEVEL OF EVIDENCE

Level III.

Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

To date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA.

METHODS

We systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty.

RESULTS

We included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types.

CONCLUSION

Based on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important.

LEVEL OF EVIDENCE

Level III, meta-analysis.

The Impact of Psychological Factors and Their Treatment on the Results of Total Knee Arthroplasty

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There is a growing body of evidence implicating psychosocial factors, including anxiety, depression, kinesiophobia, central sensitization, and pain catastrophizing, as negative prognostic factors following total knee arthroplasty (TKA).

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Symptoms of anxiety and depression likely represent risk factors for negative outcomes in patients undergoing TKA. However, few studies have assessed the impact of preoperative interventions for these conditions on postoperative outcomes.

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The Tampa Scale of Kinesiophobia and the Central Sensitization Inventory have demonstrated value in the diagnosis of kinesiophobia and central sensitization. Higher preoperative indices of kinesiophobia and central sensitization predict worse patient-reported outcomes postoperatively.

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Although evidence is limited, cognitive-behavioral therapy for kinesiophobia and duloxetine for central sensitization may help to diminish the negative impact of these preoperative comorbidities. It is important to note, however, that outside the realm of TKA, cognitive-behavioral therapy has been recognized as a more effective treatment for central sensitization than medical treatment.

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Awareness of these issues will allow surgeons to better prepare patients regarding postoperative expectations in the setting of a comorbid psychosocial risk factor. Further research into the role of preoperative assessment and possible treatment of these conditions in patients undergoing TKA is warranted.

Clinical impact of component placement in manually instrumented total knee arthroplasty : a systematic review

AIMS

The goal of the current systematic review was to assess the impact of implant placement accuracy on outcomes following total knee arthroplasty (TKA).

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Ovid Medline, Embase, Cochrane Central, and Web of Science databases in order to assess the impact of the patient-reported outcomes measures (PROMs) and implant placement accuracy on outcomes following TKA. Studies assessing the impact of implant alignment, rotation, size, overhang, or condylar offset were included. Study quality was assessed, evidence was graded (one-star: no evidence, two-star: limited evidence, three-star: moderate evidence, four-star: strong evidence), and recommendations were made based on the available evidence.

RESULTS

A total of 49 studies were identified for inclusion. With respect to PROMs, there was two-star evidence in support of mechanical axis alignment (MAA), femorotibial angle (FTA), femoral coronal angle (FCA), tibial coronal angle (TCA), femoral sagittal angle (FSA), femoral rotation, tibial and combined rotation/mismatch, and implant size/overhang or offset on PROMs, and one-star evidence in support of tibial sagittal angle (TSA), impacting PROMs. With respect to survival, there was three- to four-star evidence in support FTA, FCA, TCA, and TSA, moderate evidence in support of femoral rotation, tibial and combined rotation/mismatch, and limited evidence in support of MAA, FSA, and implant size/overhang or offset impacting survival.

CONCLUSION

Overall, there is limited evidence to suggest that PROMs are impacted by the accuracy of implant placement, and malalignment does not appear to be a significant driver of the observed high rates of patient dissatisfaction following TKA. However, FTA, FCA, TCA, TSA, and implant rotation demonstrate a moderate-strong relationship with implant survival. Efforts should be made to improve the accuracy of these parameters in order to improve TKA survival. Cite this article: Bone Joint J 2021;103-B(9):1449-1456.

Preoperative Mental Health Influences Patient-Reported Outcome Measures and Satisfaction After Revision Total Knee Arthroplasty

BACKGROUND

A higher prevalence of mental health conditions has been reported in patients undergoing revision total knee arthroplasty (rTKA). This study investigated the effect of preoperative mental health on patient-reported outcome measures (PROMs) and satisfaction after rTKA.

METHODS

A total of 245 patients who underwent rTKA in 2004-2018 were identified from our institutional joint registry. The most common indications were aseptic loosening (n = 111), infection (n = 70), and instability (n = 35). 36-item Short-Form health survey (SF-36) mental component summary (MCS) was used to stratify the cohort into: Low-MCS (SF-36 MCS <50; n = 112) and control (SF-36 MCS ≥50; n = 133) groups. Knee Society score, Oxford knee score, SF-36 physical score, and a satisfaction questionnaire were used to compare the low-MCS and control at 6 months and 2 years.

RESULTS

All PROMs were poorer in the low-MCS group at 6 months and 2 years. However, both groups demonstrated a comparable improvement in each PROM and a similar proportion attained the minimal clinically important difference. Fewer patients in the low-MCS group were satisfied at 2 years (72.2% vs 84.5%, P = .045). Lower preoperative SF-36 MCS was independently associated with increased odds of dissatisfaction (OR 1.037, 95% CI 1.004-1.070, P = .027). Although the change in SF-36 MCS was greater in the low-MCS group, the final value remained lower at 2 years.

CONCLUSION

While patients with poor mental health had inferior PROMs preoperatively and postoperatively, a similar percentage experienced a clinically meaningful improvement at 2 years. Perioperative optimization of psychological factors should still be emphasized as these patients were at a higher risk of dissatisfaction after rTKA.

Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients

PURPOSE

We aimed to test the utility of screening for depressive symptoms in the hand surgical office focusing on chances of heightened depressive symptoms in patients with no history of diagnosed depression and by quantifying ongoing depressive symptoms among patients diagnosed with depression accounting for antidepressant use. The clinical importance of this study was predicated on the documented negative association between depressive symptoms and hand surgical outcomes.

METHODS

This cross-sectional study analyzed 351 patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. Adult patients completed self-administered Patient-Reported Outcomes Measurement Information System (PROMIS) Depression computer adaptive tests at registration. Health records were examined for a past medical history of diagnosed depression and whether patients reported current use of prescription antidepressants. Mean PROMIS Depression scores were compared by analysis of variance (groups: no diagnosed depression, depression without medication, depression with medication). Four points represented a clinically relevant difference in PROMIS Depression scores between groups and Depression scores greater than 59.9 were categorized as having heightened depressive symptoms.

RESULTS

Sixty-two patients (18%) had been diagnosed with depression. Thirty-four of these patients (55%) reported taking antidepressant medications. The PROMIS Depression scores indicated greater current depressive symptoms among patients with a history of diagnosed depression when not taking antidepressants (11 points worse than unaffected) and also among patients taking antidepressants (7 points worse than unaffected). Heightened depressive symptoms were detected in all groups but were more prevalent among those diagnosed with depression (36% with no medication, 29% with antidepressant medication) compared with unaffected patients (7%).

CONCLUSIONS

Depression screening for heightened depressive symptoms identifies 1 in 14 patients without diagnosed depression and 1 in 3 patients diagnosed with depression as having currently heightened depressive symptoms. Hand surgeons can use PROMIS Depression screening in all patients and using this to guide referrals for depression treatment to ameliorate one confounder of hand surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom prevalence study II.

The effectiveness of internet-based telerehabilitation among patients after total joint arthroplasty: A systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

The aim of this review was to systematically evaluate the available evidence on the effectiveness of internet-based telerehabilitation among patients after total joint arthroplasty regarding pain, range of motion, physical function, health-related quality of life, satisfaction, and psychological well-being.

METHODS

This was a systematic review with meta-analysis based on the Cochrane Handbook for Systematic Reviews of Interventions guidelines. Studies published in English or Chinese were searched using defined search periods, databases, and search terms. Two reviewers assessed independently the quality of studies. RevMan 5.3 was used for meta-analysis. Heterogeneity was assessed using the χ² and I² statistic. A random effect model and mean difference (MD) with 95% confidence interval (CI) was adopted. Standardised mean difference (SMD) was used if the outcome was measured by different scales.

RESULTS

Eleven studies with 1020 participants were analysed. Compared to face-to-face rehabilitation, internet-based telerehabilitation showed no significant difference in outcomes of pain (SMD-0.11, 95% CI-0.32 to 0.10), range of motion in flexion (MD 0.65, 95% CI-1.18 to 2.48) and extension (MD-0.38, 95% CI-1.16 to 0.40), patient-reported physical function (SMD 0.01, 95% CI-0.15 to 0.17), health-related quality of life (SMD-0.09, 95% CI-0.26 to 0.07), satisfaction (SMD-0.04, 95% CI-0.21 to 0.14), and psychological well-being (SMD 0.10, 95% CI-0.13 to 0.33). Internet-based telerehabilitation showed better outcomes in physical functional tests (SMD-0.54, 95% CI-1.08 to-0.01).

DISCUSSION

This review suggests that internet-based telerehabilitation has comparable effectiveness to face-to-face rehabilitation on rehabilitation outcomes among patients after total joint arthroplasty.

Do Patients With Psychological Distress Have Poorer Patient-Reported Outcomes After Total Hip Arthroplasty?

BACKGROUND

Patients with psychological distress are likely to have poorer short-term functional outcomes after total knee arthroplasty. However, the influence of psychological distress on the outcomes of total hip arthroplasty (THA) is relatively understudied. Previous studies also had short follow-ups of 1 year or less. We examined the influence of psychological distress on patient-reported outcomes and satisfaction, and analyzed the change in mental health after THA at a minimum of 2 years.

METHODS

Prospectively collected data of 1384 patients undergoing primary THA in 2001-2015 were reviewed. Patients were assessed using the Oxford Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and 36-item Short-Form health survey Physical Component Summary and Mental Component Score (MCS). Patients were stratified into those with psychological distress (MCS < 50, n = 720) and those without (MCS ≥ 50, n = 664). Multiple regression analysis was used to control for age, gender, body mass index, and baseline scores. The rate of satisfaction and expectation fulfillment was also analyzed.

RESULTS

Distressed patients had a poorer Physical Component Summary at 6 months. However, there was no difference in patient-reported outcomes at 2 years. A higher proportion of distressed patients attained the minimal clinically important difference for Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index, while 92.2% of distressed patients and 92.9% of nondistressed patients were satisfied at 2 years (P = .724). There was no difference in MCS after 6 months. The percentage of distressed patients also declined from 41.8% to 27.3%.

CONCLUSION

Patients with psychological distress achieved a comparable level of function, quality of life, and satisfaction 2 years after THA. Undergoing THA may also lead to mental health improvement in a subgroup of distressed patients.