Impact of Resilience on Outcomes of Total Knee Arthroplasty

Association Between Preoperative Patient Resilience and Patient-Reported Outcomes After Rotator Cuff Repair

Background

Mental and emotional health can affect outcomes after orthopaedic surgery, and patient resilience has been found to be significantly related to postoperative functional outcomes.

Purpose

To evaluate the relationship between preoperative patient resilience and 2-year postoperative patient-reported outcomes after rotator cuff repair (RCR). It was hypothesized that patients with low preoperative resilience will have worse patient-reported outcomes at 2 years after RCR versus those with high resilience.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent primary arthroscopic RCR in 2020 at a single institution and completed the Brief Resilience Scale (BRS) preoperatively were identified. Other inclusion criteria were American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores at the 2-year follow-up. Outcomes were compared in patients as divided into low resilience (BRS score >1 SD below the mean), normal resilience (BRS score ≤1 SD of the mean), and high resilience (BRS score >1 SD above the mean) groups.

Results

Overall, 100 patients (52 male, 48 female; mean age, 60 ± 9 years) were included in this study. Mean BRS scores did not change significantly from preoperative to 2-year follow-up (3.8 ± 0.7 vs 3.9 ± 0.8, P = .404). All patients had preoperative ASES scores. Low-resilience patients (n = 17) had significantly lower preoperative ASES scores compared with normal (n = 64) and high resilience (n = 19) patients (35 vs 42 vs 54, respectively; P = .022). There were no significant group differences in postoperative outcomes (revision rate, ASES score, ASES score improvement from preoperative to 2-year follow-up, or SANE score). Multivariate analysis indicated that preoperative resilience was not significantly associated with ASES score improvement (β estimate = -5.64, P = .150), while resilience at 2-year follow-up was significantly related to ASES score improvement (β estimate = 6.41, P = .031).

Conclusion

Patient-reported outcomes at 2-year follow-up did not differ based on preoperative patient resilience for arthroscopic RCR patients. Multivariate analysis also showed that preoperative resilience was not associated with improvement in ASES scores; however, resilience at 2-year follow-up was associated with ASES score improvement.

Anatomic shoulder arthroplasty: the correlation between patient resilience, mental health, and outcome

BACKGROUND

Recovery from anatomic shoulder arthroplasty may be enhanced in patients with good mental health and the resilience to participate in the prescribed postoperative rehabilitation program. To test this concept, we utilized validated and reliable scales in determining whether resilience and mental health are associated with the outcome of anatomic arthroplasty.

METHODS

Three hundred ninety-nine patients (195 ream and run [RnR] and 204 anatomic total shoulder arthroplasty [aTSA]) were surveyed at a mean follow-up of 6.3 ± 3.3 years. Preoperative variables included age, sex, body mass index, history of prior shoulder surgery, diabetes, visual analog scale for pain, Simple Shoulder Test (SST) scores, and Veteran's RAND 12 Mental Component Score (VR-12 MCS). Outcomes collected included the SST, American Shoulder and Elbow Surgeons (ASES) score, revision rate, and patient satisfaction. Resilience was documented using the Connor-Davidson Resilience Scale 10 (CD-RISC 10) at latest follow-up. Univariable and multivariable regression analyses were used to identify factors significantly associated with follow-up postoperative SST, ASES, and satisfaction.

RESULTS

In the univariable analysis, CD-RISC 10 was positively correlated with postoperative SST, ASES, and satisfaction after both RnR and aTSA. The mean CD-RISC 10 scores were higher in the RnR cohort (34.3 ± 4.8 vs. 32.5 ± 6.2 for aTSA, P < .001). Male sex and lower preoperative visual analog scale for pain were correlated with higher ASES after RnR; VR-12 MCS was positively correlated with all outcomes except SST after RnR. In the multivariable linear regression analysis, CD-RISC 10 was independently associated with postoperative SST, ASES and satisfaction scores in aTSA patients. In the RnR cohort, CD-RISC 10 was only correlated with satisfaction. VR-12 MCS was correlated with ASES and satisfaction after RnR.

DISCUSSION

In this study of anatomic arthroplasties, increased resilience and better mental health were correlated with better outcomes. RnR patients had higher resilience than aTSA patients. Greater resilience was associated with better outcomes after aTSA. Better mental health was associated with superior outcomes after the ream and run procedure.

Preoperative Resilience and Improvement in Patient-Reported Outcomes After Lumbar Spinal Fusion

BACKGROUND

It is incompletely understood how preoperative resilience affects 1-year postoperative outcomes after lumbar spinal fusion.

METHODS

Patients undergoing open lumbar spinal fusion at a single-center institution were identified between November 2019 and September 2022. Preoperative resilience was assessed using the Brief Resilience Scale. Demographic data at baseline including age, gender, comorbidities, and body mass index (BMI) were extracted. Patient-reported outcome measures including Oswestry Disability Index, PROMIS (Patient-Reported Outcomes Measurement Information System) Global Physical Health, PROMIS Global Mental Health (GMH), and EuroQol5 scores were collected before the surgery and at 3 months and 1 year postoperatively. Bivariate correlation was conducted between Brief Resilience Scale scores and outcome measures at 3 months and 1 year postoperatively.

RESULTS

Ninety-three patients had baseline and 1 year outcome data. Compared with patients with high resilience, patients in the low-resilience group had a higher percentage of females (69.4% vs. 43.9%; P = 0.02), a higher BMI (32.7 vs. 30.1; P = 0.03), and lower preoperative Global Physical Health (35.8 vs. 38.9; P = 0.045), GMH (42.2 vs. 49.2; P < 0.001), and EuroQol scores (0.56 vs. 0.61; P = 0.01). At 3 months postoperatively, resilience was moderately correlated with GMH (r = 0.39) and EuroQol (r = 0.32). Similarly, at 1 year postoperatively, resilience was moderately correlated with GMH (r = 0.33) and EuroQol (r = 0.34). Comparable results were seen in multivariable regression analysis controlling for age, gender, number of levels fused, BMI, Charlson Comorbidity Index, procedure, anxiety/depression, and complications.

CONCLUSIONS

Low preoperative resilience can negatively affect patient-reported outcomes 1 year after lumbar spinal fusion. Resiliency is a potentially modifiable risk factor, and surgeons should consider targeted interventions for at-risk patient groups.

Resilience Improves Patient-Reported Outcomes After Orthopaedic Trauma

OBJECTIVES

To analyze the relationship between patient resilience and patient-reported outcomes after orthopaedic trauma.

METHODS

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Single Level 1 Trauma Center.

PATIENT SELECTION CRITERIA

Patients were selected based on completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) and Brief Resilience Scale (BRS) surveys 6 months after undergoing operative fracture fixation following orthopaedic trauma. Patients were excluded if they did not complete all PROMIS and BRS surveys.

OUTCOME MEASURES AND COMPARISONS

Resilience, measured by the BRS, was analyzed for its effect on patient-reported outcomes, measured by PROMIS Global Physical Health, Physical Function, Pain Interference, Global Mental Health, Depression, and Anxiety. Variables collected were demographics (age, gender, race, body mass index), injury severity score, and postoperative complications (nonunion, infection). All variables were analyzed with univariate for effect on all PROMIS scores. Variables with significance were included in multivariate analysis. Patients were then separated into high resilience (BRS >4.3) and low resilience (BRS <3.0) groups for additional analysis.

RESULTS

A total of 99 patients were included in the analysis. Most patients were male (53%) with an average age of 47 years. Postoperative BRS scores significantly correlated with PROMIS Global Physical Health, Pain Interference, Physical Function, Global Mental Health, Depression, and Anxiety ( P ≤ 0.001 for all scores) at 6 months after injury on both univariate and multivariate analyses. The high resilience group had significantly higher PROMIS Global Physical Health, Physical Function, and Global Mental Health scores and significantly lower PROMIS Pain Interference, Depression, and Anxiety scores ( P ≤ 0.001 for all scores).

CONCLUSIONS

Resilience in orthopaedic trauma has a positive association with patient outcomes at 6 months postoperatively. Patients with higher resilience report higher scores in all PROMIS categories regardless of injury severity. Future studies directed at increasing resilience may improve outcomes in patients who experience orthopaedic trauma.

LEVEL OF EVIDENCE

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

Association of Preoperative Patient Resilience With Postoperative Patient-Reported Outcomes and Sleep Quality Following Arthroscopic Rotator Cuff Repair: A Systematic Review

Recent studies have shown that low preoperative resilience may lead to inferior outcomes following arthroscopic rotator cuff repair. Therefore, the purpose of this systematic review is to evaluate whether preoperative patient resilience is associated with outcome measures, including patient-reported outcome measurements (PROMs) and sleep quality, following arthroscopic rotator cuff repair. To perform the review, a literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the PubMed and Embase databases to gather studies related to the influence of preoperative resilience on postoperative outcomes of rotator cuff repair. Methodological quality and risk of bias were assessed using the Methodological Index for Non-randomized Studies (MINORS). Seven studies with 584 patients were included. Of 36 total reported postoperative outcomes, including PROMs and sleep quality, 14 had a significant positive correlation with higher preoperative resilience. One study reported that higher resilience was significantly correlated with worse sleep quality at a two-week follow-up but not at further follow-ups of up to 24 weeks. Significant differences in outcomes between patients with varying levels of resilience were assessed in five studies, all of which found that patients with higher resilience had significantly better outcomes or no significant differences in outcomes between patients with varying levels of preoperative resilience. In no study was it reported that patients with low resilience had better outcomes. Overall, approximately half of all reported postoperative outcome data was found to be significantly associated with preoperative resilience. Therefore, clinicians should preemptively identify those with low resilience and administer psychological interventions to limit inferior outcomes following arthroscopic rotator cuff repair.

Mental Robustness May Be Associated With Improved Physical Function in Bilateral Total Knee Arthroplasty Patients

BACKGROUND

In accordance with the high incidence of bilateral knee osteoarthritis, many patients have undergone bilateral total knee arthroplasty (BTKA). Whether patients undergo bilateral procedures in a staged or simultaneous fashion, the physical and mental burden of undergoing 2 major orthopedic procedures is considerable. The aims of this study were to (1) investigate differences between minimal clinically important difference (MCID) achievement between staged versus simultaneous BTKA, and (2) identify the patient variables, specifically mental scores, that were associated with MCID achievement in patients undergoing BTKA.

METHODS

Simultaneous and staged BTKA patients within a single health care network from 2016 to 2021 were retrospectively reviewed. Patient demographics, surgery details, and Patient-Reported Outcome Measurement Information System Physical Function Short Forms 10a (PROMIS PF10a), PROMIS Mental scores, and Knee Disability Osteoarthritis Outcome Scores (KOOS) were reviewed. Preoperative and postoperative patient-reported outcome measures were collected before the first total knee arthroplasty (TKA) and after the second TKA, respectively, in staged BTKA patients. The final cohort consisted of 249 patients, with an average age of 66 years (range, 21 to 87), 63% women, and an average body mass index of 32 (range, 20 to 52), at a mean follow-up of 1.1 years (range, 0.5 to 2.4). Multivariate regressions were performed on MCID PF10a and KOOS achievement, as well as whether the BTKA was performed simultaneously versus staged.

RESULTS

A preoperative PROMIS Mental score in the upper 2 quartiles was associated with MCID PF10a achievement in BTKA. Men and surgeries performed at an Academic Medical Center were negatively associated with the achievement of MCID KOOS. Interestingly, those who underwent simultaneous BTKA were less likely to achieve MCID KOOS than those who underwent a staged BTKA.

CONCLUSIONS

Preoperative mental robustness may be positively associated with improved physical function outcome in BTKA patients.

Increased patient resilience scores are related to positive postoperative outcomes in rotator cuff repairs

HYPOTHESIS

We sought to determine whether patients' preoperative resilience scores predict postoperative outcomes in arthroscopic rotator cuff repair surgery.

METHODS

Patients were prospectively enrolled and underwent data collection preoperatively and at 3, 6, 12, and 24 months postoperatively. Data collected included demographic characteristics and the Brief Resilience Scale (BRS) score, visual analog scale score, Veterans RAND 12-Item Health Survey scores (mental component [VR-12M] and physical component [VR-12P]), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numeric Evaluation score, and Simple Shoulder Test (SST) score.

RESULTS

In total, 131 patients had complete 1- or 2-year postoperative outcome measures. Female patients comprised 56.5% of our sample, and the average age was 57.6 years. Between the low, normal, and high resilience groups, there were significant differences in the VR-12M scores at 0, 12, and 24 months postoperatively (P < .01 for all). The VR-12P scores at 12 months were 44.2, 47.4, and 49.8 in the low, normal, and high resilience groups, respectively, showing a trend upward, but this failed to reach the level of significance (P = .08). The SST scores of the low, normal, and high resilience groups at 12 months were 69.1, 79.9, and 85.1, respectively, again showing a trend upward, but this failed to reach the level of significance (P = .07). The SST scores at 0 and 24 months did not differ between groups. There were no significant differences in American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores at 0, 12, or 24 months postoperatively. We found a significant positive correlation between the BRS score and SST score at 12 months (R = 0.18), VR-12M score at 12 months (R = 0.38), VR-12M score at 24 months (R = 0.31), and VR-12P score at 12 months (R = 0.21).

CONCLUSIONS

Our study provides evidence that BRS scores in patients undergoing arthroscopic rotator cuff repair are related to postoperative outcomes, measured through the VR-12M and SST scores at 2-year follow-up.

Resilience as a psychiatric factor affecting outcomes after total joint arthroplasty: a systematic review

INTRODUCTION

Mental and psychiatric status continue to be underscreened prior to total joint arthroplasty (TJA). Research on the role of resilience as a psychiatric factor affecting TJA outcomes remains limited. Therefore, our systematic review sought to evaluate the impact of patient resilience in TJA.

METHODS

A systematic review of the literature from the Pubmed, MEDLINE, EBSCOhost, and Google Scholar online databases was performed in abidance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting on outcomes following primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) segregated by patient resilience were included. Case reports, reviews, meta-analyses, and conference abstracts were excluded. Primary outcomes of interest included patient-reported outcomes (PROs), surgical outcomes, and postoperative opioid consumption.

RESULTS

Twelve articles were included reporting on a total of 1,577 TJAs. There was a strong agreement that the Patient Reported Outcomes Measurement Information System (PROMIS)-Physical Health and Mental Health components were strongly predicted by patient resilience. However, there was inconclusive evidence regarding the impact of resilience on UCLA Activity Scales (UCLA) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) outcomes as well as postoperative hip and knee function. Similarly, conflicting evidence was presented regarding the effect of resilience on length of stay (LOS). Greater resilience was associated with reduced opioid usage in the immediate inpatient postoperative period. However, resilience had no significant effect on opioid requirements in the postoperative outpatient follow-up time frame.

CONCLUSION

The present analysis demonstrated mixed, inconclusive evidence regarding the impact of resilience on postoperative outcomes. The paucity of research evaluating this relationship warrants further investigation, examining both short and long-term outcomes. Due to the limited literature evaluating resilience as a predictor of outcomes following TJA, we cannot definitively rule out resilience as a valuable metric and must further examine its utility as a preoperative screening tool.

LEVEL OF EVIDENCE

III.

Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist

Purpose

To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery.

Methods

A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines.

Results

Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function.

Conclusions

Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn.

Level of Evidence

Level IV, systematic review of level II-IV studies.

Preoperative Low Resilience Is Associated With Female Patients, Whereas High Resilience Is Associated With Improved Mental Health Scores During Anterior Cruciate Ligament Reconstruction

PURPOSE

To evaluate the relationship between resilience, as measured by the Brief Resilience Scale (BRS), and patient-reported outcome measures (PROMs) after primary anterior cruciate ligament reconstruction (ACLR).

METHODS

A cohort of 72 patients undergoing primary ACLR were followed for a minimum of 2 years. Preoperative BRS scores were collected, and patients were categorized into low resilience (LR), normal resilience (NR), and high resilience (HR). PROMs including the visual analog scale (VAS), measuring overall pain level from 0 to 10, the Veterans Rand (VR) 12-Item Health Survey Physical Component and Mental Components, Knee Injury and Osteoarthritis Outcomes Score, and Marx Activity Rating Scale were collected preoperatively as well as up to 2 years postoperatively and compared among the various resilience groups.

RESULTS

BRS scores were significantly associated with VAS, VR 12-Item Health Survey Mental Component, and KOOS outcome scores. There was a significant difference among all 3 resilience groups (P = .0382) in change of VAS score from baseline to 2 years postoperatively, with a mean difference of 2.5 points, 1.1 points, and 0.7 points for LR, NR, and HR groups, respectively. There was a significant association of greater VR 12-Item Health Survey Mental Component scores, with greater resilience scores preoperatively (P < .0001) and at both 1 (P = .0034) and 2 years (P = .0235) postoperatively. Greater resilience scores were associated with greater KOOS scores at 1 year postoperatively (P = .0270). Female patients were more likely to fall into the LR group (80%).

CONCLUSIONS

In this cohort of patients undergoing ACLR, low resilience is positively associated with greater improvement in pain, and female patients tend to fall more into the LR group. At 1 year postoperatively, greater resilience scores were positively associated with greater aggregated KOOS scores. At 1 and 2 years postoperatively, greater resilience was positively associated with improved VR-12M scores.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Analyzing Resilience in the Orthopedic Sports Medicine Patient Population

Little research has been done to compare resilience, as measured by the Brief Resilience Scale (BRS), across common sports medicine patient populations. Our purpose was to investigate resilience levels across sports medicine patient populations. All patients who underwent reconstruction of the anterior cruciate ligament (ACLR), partial meniscectomy (PM), meniscal repair (MR), rotator cuff repair (RCR), or shoulder stabilization (SS) between January 1 and June 30, 2020, were screened for inclusion. At our institution, BRS scores are routinely collected during the preoperative period. Patients with preoperative BRS scores available were included for analysis. Patients who were eligible on the basis of ACLR who underwent concomitant PM or MR were included in the ACL group. A total of 655 patients with a median age of 49 years were included in analysis. The median preoperative resilience score across all patients was 3.83 (interquartile range, 3.50-4.17), and the highest scores were seen in the ACLR group (median, 4.00; interquartile range, 3.67-4.17). On multivariate regression, scores were significantly and independently lower in the PM and RCR groups. Male patients were found to have significantly higher scores than female patients overall (P=.028), but in subgroup analysis by pathology, this effect was only seen in the SS and PM groups. Psychological factors are important to consider when surgically treating patients, and resilience specifically may play a role in predicting treatment success. Patients undergoing PM and RCR tend to report lower resilience scores than patients undergoing ACLR at preoperative baseline. [Orthopedics. 2024;47(2):95-100.].

Resilience of Patients Undergoing Knee and Shoulder Arthroscopy Procedures

INTRODUCTION

Resilience is a person's capacity to overcome adversity. The purpose was to determine what patient factors correlate with resilience using the Brief Resilience Score. We hypothesize that characteristics of female sex, younger age, Workers' Compensation status, and preoperative opioid use are predictors of a lower preoperative resilience score and that patients with positive psychosocial factors would have higher resilience scores.

METHODS

Eight hundred nine patients undergoing knee or shoulder arthroscopy were preoperatively categorized into low, normal, and high-resilience groups. Preoperative patient-reported outcome measures (PROMs) and demographics were assessed. Statistical analyses evaluated differences in demographics and PROMs between resilience groups.

RESULTS

Analysis disclosed notable differences between low, normal, and high-resilience groups regarding demographics and PROMs. High resilience was seen in older patients, male patients, and patients with positive psychosocial factors. Low resilience scores were discovered in Workers' Compensation patients and those with a history of preoperative opioid use. No difference in resilience scores was observed between smokers and nonsmokers.

DISCUSSION

Preoperative resilience score is associated with age, sex, preoperative opioid use, Workers' Compensation status, and smoking status of patients undergoing knee or shoulder arthroscopy.

Resilience correlates with patient-reported outcome measures at a minimum of 2 years after arthroscopic rotator cuff repair

Aims

We aimed to evaluate the correlation between preoperative and postoperative resilience scores and postoperative outcomes at minimum 2-year follow-up after arthroscopic rotator cuff repair.

Methods

We prospectively enrolled 98 patients who underwent rotator cuff repair. We assessed resilience using the Brief Resilience Scale. Postoperatively, we obtained patient-reported outcomes measures including American Society of Shoulder and Elbow Surgeons scores, Single Assessment Numeric Evaluation, and Patient-Reported Outcome Measurement Information System Global Health-10 at minimum 2-year follow-up. We used Spearman correlation coefficients (r) to assess the relationship between variables.

Results

Ninety-one of 98 patients (93%) provided follow-up at an average of 32 months. Preoperative Brief Resilience Scale did not show a statistically significant correlation with American Society of Shoulder and Elbow Surgeons (r = 0.156; p = 0.142). However, preoperative Brief Resilience Scale showed statistically significant correlations with Patient-Reported Outcome Measurement Information System Global Health-10 (r = 0.290; p = 0.005) and Single Assessment Numeric Evaluation (r = 0.259; p = 0.014). Postoperative Brief Resilience Scale showed statistically significant correlations with American Society of Shoulder and Elbow Surgeons (r = 0.291; p = 0.005), Single Assessment Numeric Evaluation (r = 0.384; p < 0.001) and Patient-Reported Outcome Measurement Information System Global Health-10 (r = 0.515; p < 0.001).

Discussion

Resilience may be a valuable predictor of patients at risk of having suboptimal outcomes after rotator cuff repair and a target to improve surgical outcomes through non-surgical means.

A diarized journey: an interpretative phenomenological analysis of the older person's lived experience of a hip or knee replacement within a fast-track programme

BACKGROUND

For the older person living with end-stage hip or knee osteoarthritis, a hip or knee replacement can be a traumatic event, influencing the physical, physiological, psychological, social and economic facets of daily living. This interpretative phenomenological study aimed to reveal and interpret the daily lived experiences of the older person before, during and after a primary total hip or knee replacement surgery in a fast-track programme in South Africa.

METHODS

A qualitative interpretive phenomenological study, collecting data through solicited diaries and reflexive member validation interviews from seven participants aged 65-75 years, who underwent a primary elective hip or knee replacement surgery. The surgical fast-track process and data collection process happened simultaneously. Data collection from the solicited diary started before surgery, continued during the surgery process and finished six weeks after surgery and this was followed with reflexive member validation interviews. Interpretative phenomenological analysis was used throughout the three phases of the fast-track programme.

RESULTS

Three superordinate themes developed during the three phases of surgery: "The holistic impact of pain on daily quality of life", "Finding ways to cope", and "Transition between independence and dependence and back". Although former research confirms the physical impact of osteoarthritis on the older person and the success of fast-track programmes for subsequent hip and knee replacements, this study contributes to the holistic impact of the surgery on participants' daily lives. The diarized journey of individuals through the psychological, psychosocial, physical, professional, and spiritual experience are described and interpreted in this study.

CONCLUSIONS

Across the solicited diaries, it was clear that pain as catalyst impacted the daily activities of the individual physically, psychologically, and psychosocially. Pain was subjectively present at different intensities during all the phases of the replacement surgery, impairing mobilization and triggering roller-coaster emotions. In order to cope with physical and emotional difficulties while preparing and adjusting to the environment, participants reflected on social support, physical and professional support, and spirituality. Throughout the preparation, hospitalization and the recovery process, the transition between independence, dependence, and back to independence was significant, reinforcing the individual's determination to recover.

Predicting chronic postsurgical pain: current evidence and a novel program to develop predictive biomarker signatures

ABSTRACT

Chronic pain affects more than 50 million Americans. Treatments remain inadequate, in large part, because the pathophysiological mechanisms underlying the development of chronic pain remain poorly understood. Pain biomarkers could potentially identify and measure biological pathways and phenotypical expressions that are altered by pain, provide insight into biological treatment targets, and help identify at-risk patients who might benefit from early intervention. Biomarkers are used to diagnose, track, and treat other diseases, but no validated clinical biomarkers exist yet for chronic pain. To address this problem, the National Institutes of Health Common Fund launched the Acute to Chronic Pain Signatures (A2CPS) program to evaluate candidate biomarkers, develop them into biosignatures, and discover novel biomarkers for chronification of pain after surgery. This article discusses candidate biomarkers identified by A2CPS for evaluation, including genomic, proteomic, metabolomic, lipidomic, neuroimaging, psychophysical, psychological, and behavioral measures. Acute to Chronic Pain Signatures will provide the most comprehensive investigation of biomarkers for the transition to chronic postsurgical pain undertaken to date. Data and analytic resources generatedby A2CPS will be shared with the scientific community in hopes that other investigators will extract valuable insights beyond A2CPS's initial findings. This article will review the identified biomarkers and rationale for including them, the current state of the science on biomarkers of the transition from acute to chronic pain, gaps in the literature, and how A2CPS will address these gaps.

Patients With Low Resilience Scores Have Significantly Worse Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction Than Patients With Normal or High Resilience Scores

Purpose

To evaluate the relationship between patient resilience and patient-reported outcome measures (PROMS) after primary anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent an ACL reconstruction by a single surgeon between January 2012 and June 2020 were identified by an institutional query using Current Procedural Terminology codes. Patients were included if they (1) underwent a primary ACL reconstruction and (2) had a minimum of 2 years' follow-up. Data were retrospectively collected regarding demographics, surgical details, visual analog scale (VAS) scores, and 12-item short form survey (SF-12) scores. Resilience scores were obtained via the Brief Resilience Scale questionnaire. Stratification into low (LR), normal (NR), and high resilience (HR) was based on standard deviation from mean Brief Resilience Scale score to determine differences in PROMS between groups.

Results

One-hundred eighty-seven patients were identified by the institutional query. Of the 187 patients, 180 met inclusion criteria. Seven patients underwent revision ACL reconstruction and were excluded from the study. One-hundred three patients (57.2%) completed the postoperative questionnaire and were included. Patients in the NR group and HR group had significantly greater postoperative SF-12 scores (P < .001) and lower postoperative VAS pain scores (P < .001) when compared with those of the LR group. This trend was again shown with breakdown of the SF-12 into physical and mental aspects, each of which were significantly greater in either the NR group or HR group when compared with the LR group (P < .001). Overall, 97.9% and 99.0% of patients had changes in their SF-12 total and VAS pain scores respectively that exceeded the minimal clinically important difference for the cohort.

Conclusions

Patients with lower resilience scores have worse PROMs and increased pain than patients with greater resilience at a minimum of 2-year follow-up after ACL reconstruction.

Level of Evidence

Level IV, prognostic case series.

Associating Outcomes After Hip Arthroscopy With Patient Resilience

Background

Higher patient resilience has been shown to be associated with improved patient-reported outcome measures (PROMs) at 6 months after hip arthroscopy.

Purpose

To examine the relationship between patient resilience and PROMs at minimum 2 years after hip arthroscopy.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were 89 patients (mean age, 36.9 years; mean follow-up, 4.6 years). Patient demographics, surgical details, and preoperative International Hip Outcome Tool-12 (iHOT-12) and visual analog scale (VAS) pain scores were collected retrospectively. Postoperative variables were collected via a survey and included the Brief Resilience Scale (BRS), Patient Activation Measure-13 (PAM-13), Pain Self-efficacy Questionnaire-2 (PSEQ-2), VAS satisfaction, and postoperative iHOT-12, and VAS pain scores. Based on the number of standard deviations from the mean BRS score, patients were stratified as having low resilience (LR; n = 18), normal resilience (NR; n = 48), and high resilience (HR; n = 23). Differences in PROMs were compared between the groups, and a multivariate regression analysis was performed to assess the relationship between pre- to postoperative change (Δ) in PROMs and patient resilience.

Results

There were significantly more smokers in the LR group compared with the NR and HR groups (P = .033). Compared with the NR and HR groups, patients in the LR group had significantly more labral repairs (P = .006), significantly worse postoperative iHOT-12, VAS pain, VAS satisfaction, PAM-13, and PSEQ-2 scores (P < .001 for all), and significantly lower ΔVAS pain and ΔiHOT-12 scores (P = .01 and .032, respectively). Regression analysis showed significant associations between ΔVAS pain and NR (β = -22.50 [95% CI, -38.81 to -6.19]; P = .008) as well as HR (β = -28.31 [95% CI, -46.96 to -9.67; P = .004) and between ΔiHOT-12 and NR (β = 18.94 [95% CI, 6.33 to 31.55]; P = .004) as well as HR (β = 20.63 [95% CI, 6.21 to 35.05]; P = .006). Male sex was a significant predictor of ΔiHOT-12 (β = -15.05 [95% CI, -25.42 to -4.69]; P = .006).

Conclusion

The study results indicate that lower postoperative resilience scores were associated with significantly worse PROM scores, including pain and satisfaction, at 2 years after hip arthroscopy.

Association between Psychological Resilience and Self-Rated Health in Patients with Knee Osteoarthritis

This study aimed to evaluate whether psychological resilience is an independent factor of self-rated health (SRH) among patients with knee osteoarthritis (KOA). A cross-sectional study with convenience sampling was designed. Patients with doctor-diagnosed KOA were recruited from the orthopedic outpatient departments of a hospital in southern Taiwan. Psychological resilience was measured by the 10-item Connor-Davidson Resilience Scale (CD-RISC-10), and SRH was measured by three items, including the current SRH, the preceding year-related SRH, and age-related SRH. The three-item SRH scale was categorized as "high" and "low-moderate" groups by terciles. Covariates included KOA history, site of knee pain, joint-specific symptoms measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), comorbidity measured by Charlson Comorbidity Index, and demographic variables (i.e., age, sex, education attainment, and living arrangements). A multiple logistic regression was used to detect the independent variables with significant odds ratios that can predict "high" SRH among participants. Results: In total, 98 patients with KOA (66 women and 32 men) with a mean age (±SD) of 68.3 ± 8.5 years were enrolled and were analyzed. A total of 38.8% (n = 38) of participants were categorized as "high SRH", while 61.2% (n = 60) were categorized as "low-moderate SRH". Multiple logistic regression showed that CD-RISC-10 had an increased odds ratio (OR) for high SRH (OR [95% CI] = 1.061 [1.003-1.122]; p = 0.038), whereas bilateral pain (vs. unilateral pain), WOMAC stiffness, and WOMAC physical limitation showed a decreased OR for high SRH (0.268 [0.098-0.732], 0.670 [0.450-0.998], and 0.943 [0.891-0.997], respectively). Our findings provide evidence indicating that psychological resilience plays a significant positive role in the SRH in our study sample. Further research is required to extend the growing knowledge regarding the application of psychological resilience on KOA.

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.

The Impact of Patient Resilience on Discharge After Total Hip Arthroplasty

BACKGROUND

Patients who undergo total hip arthroplasty (THA) require resilience to recover and resume daily functions. Increased resilience may be an important factor for achieving improved outcomes. The purpose of this study is to examine the impact of resilience on time to discharge and on early patient-reported outcomes following primary THA.

METHODS

A retrospective review of patients who underwent primary THAs and completed the Brief Resilience Scale (BRS) was conducted from 2020 to 2021 at an urban, academic hospital. Patients were separated into 3 cohorts based on BRS score: low (1-2.99), normal (3-4.30), and high (4.31-5) resilience. Demographics, participation in same-day discharge (SDD) program, length of stay (LOS), and preoperative and 3-month postoperative scores on the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) were assessed. SDD patients were excluded from LOS analysis.

RESULTS

A total of 393 patients were included. Compared to low resilience patients, odds of being enrolled in SDD program were 1.49 and 3.01 times higher (P = .01) and 3-month HOOS JR scores improved by 4.7% and 11.7% (P = .03) for normal and high resilience patients, respectively. As resilience increased from low to normal to high in non-SDD patients, LOS significantly decreased (53.27 ± 51.92 vs 38.70 ± 28.03 vs 25.64 ± 14.48 hours, respectively; P = .001).

CONCLUSION

Increased resilience is positively associated with likelihood of SDD participation or decreased LOS. Increased resilience was associated with increased HOOS JR scores at 3 months, although this did not reach the minimal clinically important difference. The BRS may be a useful tool for predicting patients who can successfully participate in SDD or predicting LOS after primary THA.

Specific knowledge and resilience affect short-term outcome in patients following primary total hip arthroplasty

PURPOSE

The aim of the present study was to investigate the potential associations between specific knowledge, resilience and patient-reported outcome measures (PROMS) following primary total hip arthroplasty (THA).

METHODS

In a cross-sectional prospective study, consecutive patients following primary THA were included at a rehabilitation center. A novel knowledge score and the validated Connor Davidson Resilience Scale (CD-RISC) were utilized to assess patients' specific knowledge and resilience, respectively. Additionally, patients completed a qualitative questionnaire regarding the information they had received. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), as well as the University of California and Los Angeles Score (UCLA) served as primary outcome measures. Stepwise multiple regression analysis was performed to identify potential predictors of outcome.

RESULTS

A total of 103 patients at a mean age of 67.5 years (SD 10.5, 38-88) were included in the analysis at a median of 55.5 days (IQR 43-81) following primary THA. The mean knowledge and resilience scores were 3.8 (SD 1.6, 0-7) and 69.5 (SD 18.5, 0-100), respectively. Forty-seven percent of patients were afraid of harming their prosthesis and these patients had up to 59% worse WOMAC scores (p < 0.001). WOMAC scores on admission to rehabilitation were predicted by resilience and knowledge scores (R2 = 0.106, p = 0.036). UCLA scores at the time of admission were predicted by knowledge scores (R2 = 0.078, p = 0.007).

CONCLUSION

The present study demonstrated that patients with a feeling of uncertainty had an inferior short-term functional outcome following primary THA. Moreover, it could be shown that higher specific knowledge and resilience are associated with a better functional outcome according to validated PROMS. While these findings need to be prospectively validated in future studies, specific patient knowledge and resilience may have a direct impact on the outcome of primary THA.

Preoperative Resilience and Early Postoperative Outcomes following Lumbar Spinal Fusion

BACKGROUND

Previous studies identified a correlation between preoperative resilience scores and patient reported outcome measures in several surgical subspecialities. No previous studies, to our knowledge, have analyzed preoperative resilience and patient reported outcomes in lumbar spinal fusion.

METHODS

Patients undergoing lumbar spinal fusion completed the brief resilience scale preoperatively, in addition to measures of disability (Oswestry Disability index (ODI)), quality of life (PROMIS global physical and mental health scales and EuroQOL5], and leg and back pain (VAS) at pre- and 3-months postoperatively. The 3-month follow-up was selected due to the association with return to work. Multiple linear regression evaluated relationships between resilience and postoperative changes in outcomes measures, controlling for baseline values and body mass index, age, number of levels fused, and severity of comorbidities.

RESULTS

Ninety-five participants (mean age = 58 years, 56% male) completed the BRS preoperatively and outcome measures before and 3-months after lumbar fusion. On average, participants reported significant postoperative improvements on all outcome measures (p<.001). Higher preoperative resilience scores related to greater postoperative improvements in back and leg pain, global mental and physical health and EuroQol scores (p<0.05), after controlling for baseline values and other covariates. Resilience scores did not significantly correlate with postoperative changes in ODI (p>0.05).

CONCLUSIONS

Preoperative resilience is associated with improvement in pain, physical and mental health quality of life during the early postoperative period following lumbar spinal fusion. Additional research is needed to determine if improvements are maintained beyond this interval and whether resilience can be modified to optimize outcomes.

Prevalence of Cannabinoid (CBD) Use in Orthopaedic Sports Medicine Patients

Background:

Although there is some evidence that cannabinoid (CBD) products may provide a therapeutic effect for musculoskeletal pain, little is known about the usage patterns or their prevalence of use in orthopaedic sports medicine patients.

Purpose:

To report the prevalence and perceived self-efficacy of CBD products in patients evaluated in an orthopaedic sports medicine clinic.

Study Design:

Descriptive epidemiology study. Level of evidence, 2.

Methods:

The study population consisted of new patients who visited an orthopaedic surgery sports medicine clinic at a large academic center for consultation with a surgeon between August 2020 and March 2021. All patients were asked to complete a survey that assessed perceived pain and effectiveness of CBD products and other nonsurgical treatment modalities using the Single Assessment Numeric Evaluation score (range, 0-100) and the Numeric Pain Rating Scale (NRS). Descriptive factors were collected via chart review. Descriptive statistics were used to characterize the data.

Results:

Overall, 823 patients completed the survey (45.4% female; mean age, 51 years [range, 18-87 years]; mean body mass index, 28.9 [range, 17.2-58.4]). Body areas involved included 285 shoulders, 44 elbows, 76 hips, 276 knees, 58 ankles, and 77 other. Of these patients, 19% (152/823) endorsed the use of CBD products before their initial evaluation. The mean NRS for pain was significantly different between non-CBD users and CBD users (5.6 vs 6.1; P = .029). CBD users were significantly more likely to have tried other nonoperative modalities compared with nonusers, including nonsteroidal anti-inflammatory drugs (79.6% vs 69.8%; P = .032), bracing (44.7% vs 34.6%; P = .024), steroid injections (38.8% vs 21.6%; P < .001), and physical therapy (54% vs 36.1%; P < .001). In addition, 30.9% of CBD utilizers reported marijuana use compared with 2.8% of non-CBD users ( P < .001) for management of their pain.

Conclusion:

In the current study, 19% of patients had used CBD products to manage joint-related issues. Sports medicine providers should be aware of this high incidence of usage and the potential interactions CBD products may have with other treatment modalities. Further studies are needed to assess the effectiveness of CBD as a therapeutic agent and the specific interactions it has with other drugs and other forms of treatment.

The Influence of Pain and Resiliency on Foot and Ankle Surgery Outcomes

Background:

Resilience is the ability to recover after stressful events and has been shown to correlate with surgical outcomes. However, there has been minimal research on the impact of patient resiliency on foot and ankle surgical outcomes. This study aims to determine the predictive value of preoperative resiliency scores on surgical outcomes and investigate how this compares with the predictive value of pain scores.

Methods:

We conducted a retrospective review of adult patients who completed a preoperative Brief Resilience Scale (BRS) and underwent surgery between November 2019 and November 2020 with a fellowship-trained foot and ankle surgeon (N=184). Data included demographics, comorbidities, surgical details, complication and reoperation rates, pre- and postoperative opioid and benzodiazepine use, and additional patient-reported outcome measures (ie, visual analog scale [VAS], Pain Catastrophizing Scale [PCS], Pain Disability Index [PDI], Foot and Ankle Outcome Score [FAOS] pain subscale). Mean follow-up duration was 4.49 (range, 1.10-14.17) months.

Results:

BRS weakly correlated with decreased postoperative benzodiazepine use ( P=.007). PCS magnification ( P=.050) and helplessness ( P=.047) subscales weakly correlated with increased follow-up duration. PDI total score and most subscores significantly correlated with an increase in at least 1 of the following: follow-up duration, or postoperative opioid or benzodiazepine use. Neither the VAS nor FAOS pain subscore correlated with any outcome. PDI total score was the strongest predictor of postoperative opioid (β=0.334) and benzodiazepine (β=0.315) use. Preoperative opioid users had significantly higher PDI total score (user=39.3, nonuser=24.9; P=.012) and subscores (ie, social activity, sexual behavior, self-care, life-support activities).

Conclusion:

BRS is an unreliable tool for predicting outcomes in foot and ankle surgery, as it only weakly correlated with decreased benzodiazepine use. Rather, given the PDI’s strong associations with postoperative measures in this study, physicians should consider the value of preoperative PDI completion when predicting how foot and ankle surgery recipients will fare postoperatively.

Level of Evidence:

Level III, retrospective cohort study.

Impact of patient resilience on early recovery from rotator cuff repair

AIMS

We sought to evaluate early recovery from rotator cuff repair by assessing the correlation between patient resilience and postoperative shoulder pain and function, and physical and mental health.

METHODS

Patients scheduled to undergo arthroscopic rotator cuff repair were prospectively enrolled. Resilience was assessed using the Brief Resilience Scale (BRS), pain and function was measured by American Society of Shoulder and Elbow Surgeons (ASES) shoulder scores, and physical and mental health was measured by the Patient-Reported Outcome Measurement Information System Global Health-10 (PROMIS-10). All scores were obtained preoperatively and postoperatively at three- and six months. Spearman correlation coefficient (r) was used to assess the relationship between variables.

RESULTS

Ninety-eight patients ultimately underwent rotator cuff repair; 76 and 68 patients provided three- and six-month follow-up, respectively. There was no statistically significant correlation between preoperative BRS and three- and six-month ASES. However, there was a statistically significant correlation between preoperative BRS and three-month PROMIS-10 (r = 0.3763, p = 0.009) and concurrent BRS and PROMIS-10 at three months (r = 0.5657, p = 0.0025) and six months (r = 0.5308, p = 0.0025).

DISCUSSION

Resilience appears to be more predictive of global physical and mental health than shoulder pain and function in early recovery from rotator cuff repair.

Is there a difference in outcomes between the first and second surgical procedures in patients who have bilateral shoulder operations?

BACKGROUND

Some patients who have shoulder surgery on 1 shoulder go on to have surgery on their contralateral shoulder. It is unclear whether the clinical improvements following the second surgical procedure are as significant as the improvements after the first surgical procedure.

METHODS

All patients who underwent surgery on both shoulders performed by a single surgeon between March 2013 and June 2018 were eligible for inclusion. Visual analog scale (VAS) scores were obtained preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years for both shoulders. Scores were then compared based on hand dominance and which shoulder was treated first. Complications were also recorded.

RESULTS

Overall, 105 patients (210 surgical procedures) were included. Of the patients, 66 underwent bilateral open shoulder surgery and 39 underwent bilateral arthroscopic shoulder surgery. There was a significant reduction in VAS scores from preoperative to postoperative levels following surgery (5.9 before surgery vs. 1.7 after surgery). We found no difference in VAS scores at any time point when comparing whether the dominant or nondominant shoulder was operated on first. Significantly higher VAS scores were observed at 2 weeks, 6 weeks, and 3 months following the first shoulder operation compared with the second; by 6 months and beyond, there was no longer a difference.

CONCLUSION

Patients who undergo bilateral shoulder surgery have more pain in the first 3 months following their first shoulder operation compared with their second. However, there is no difference in pain scores at 6 months and beyond between shoulders.

Effect of Patient Resilience and the Single Assessment Numeric Evaluation (SANE) Score on Return to Sport Following Anterior Cruciate Ligament Reconstruction Surgery

Background

This study aims to determine the effect of resilience, as measured by the Brief Resilience Scale (BRS), and perceived self-efficacy of knee function, as measured by the Single Assessment Numeric Evaluation (SANE) score on return to sport outcomes following ACL Reconstruction (ACLR) surgery.

Methods

Seventy-one patients undergoing ACLR surgery were followed up for a minimum of one year. At six-months post-op, ACLR patients completed the BRS and the SANE score. Patients were stratified into low, normal, and high resilience groups, and outcome scores were calculated.

Results

The median return to sports participation, in months post-operatively, for the low, normal, and high resiliency groups were 7.1, 7.3, and 7.2 months, respectively (P=0.78). A multiple logistic regression analysis revealed that the SANE score was a significant predictor of return to sport at nine months when adjusted for age, sex, and BRS score (P=0.01). Patients that returned to sport by nine months demonstrated a mean SANE score of 92.7, compared to a mean of 85.7 (P=0.08). In patients who had returned to sport, neither the BRS resilience group nor the SANE score were significant predictors of the returned level of competition status (P=0.06; P=0.18).

Conclusion

The SANE score may serve as a significant predictor of return to sport when adjusted for age, sex, and BRS score. Resilience, as measured by the BRS, was not significantly associated with return to sport, but may have utility in specific patient populations.

Patient Resilience Has Moderate Correlation With Functional Outcomes, but Not Satisfaction, After Primary Unilateral Total Knee Arthroplasty

BACKGROUND

As many as 20% of patients who undergo total knee arthroplasty (TKA) are dissatisfied. Psychological factors have been shown to play a role in outcomes after TKA. The purpose of this study was to investigate the impact of patient resilience on functional outcomes and satisfaction after primary unilateral TKA.

METHODS

Eighty-six patients who underwent primary unilateral TKA by a single surgeon were studied. Primary outcomes were the Brief Resilience Scale (BRS), mental health component of the Veterans Rand 12-Item Health Survey (VR-12 MCS), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and New Knee Society Score. Correlations between BRS and dependent variables were found by using Spearmen's Rho Correlation testing. Unadjusted and adjusted regressions were run using the delta values as the dependent outcome and the BRS score as the main independent value, with data presented as an estimate of 95% confidence interval P value.

RESULTS

Resilience significantly correlated with male sex (P = .031), preoperative VR-12 MCS scores (P = .013), and postoperative VR-12 MCS scores (P < .001). BRS had moderate correlation with postoperative Knee Society Scores (KSS) Functional Activity Scores, as this approached, but did not achieve statistical significance (P = .062). There was no correlation between BRS and postoperative KSS Patient Expectations score, KSS Patient Satisfaction score, or total postoperative opioid usage.

CONCLUSIONS

Primary TKA patients with greater resilience are more likely to be male and have better mental health characteristics than those with lower resilience. Patients with greater resilience also tended to have improved knee function after TKA, although this was not statistically significant. Resiliency did not correlate with postoperative opioid consumption or patient satisfaction after TKA.

Resiliency influences postoperative outcomes following rotator cuff repair

BACKGROUND

The purpose of this retrospective review was to assess the effects of resiliency on postoperative outcome scores and complications following rotator cuff repair (RCR).

METHODS

In 2014, 49 consecutive patients underwent arthroscopic RCR for either a partial- or full-thickness tear performed by a single surgeon at a multi-location, single center. In these patients, the following scores were monitored: American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), and Life Orientation Test-Revised (LOT-R). Data collected at 4 years postoperatively were statistically analyzed by 1-way analysis of variance tests, Pearson correlations, and multivariate tests of between-subjects effects (multivariate analysis of covariance).

RESULTS

There was a statistically significant difference between cohorts and their scores of resiliency and optimism measured by the LOT-R (function portion of ASES score [ASESf], P = .048; pain portion of ASES score [ASESp], P = .003; and SST score, P = .009) as illustrated by a 1-way analysis of variance. A multivariate analysis of covariance found that LOT-R scores exhibited a significant impact on outcome scores (ASESf score, P = .043; ASESp score, P = .002; and SST score, P = .007). Correlational analysis indicated that LOT-R scores directly correlated with higher ASESp (P = .003), ASESf (P = .029), and SST (P = .018) scores. Regression line analysis provided a positive coefficient of determination value for all outcome scores.

CONCLUSION

The premise of this study was to look at mental resilience as a potential indicator of long-term outcome scores following RCR. The results of statistical analysis indicated that outcome scores are significantly different based on the degree of optimism; high levels of optimism impact and correlate to higher outcome scores. This study provides a basis for future studies of psychological resilience in the field of orthopedic surgery.

Resilience and Depression Influence Clinical Outcomes Following Primary Total Joint Arthroplasty

BACKGROUND

Resilience and depression may impact clinical outcomes following primary total joint arthroplasty (TJA). This study aimed to quantify baseline resilience and depression prevalence in patients undergoing primary TJA and evaluate their influence on patient-reported clinical outcomes.

METHODS

We prospectively enrolled 98 patients undergoing primary TJA. Exclusion criteria included patients under 18 years of age, undergoing surgery for fracture, or who underwent additional surgery during the study period. Patients completed the Brief Resilience Scale to measure resilience, Patient Health Questionnaire-9 to measure depression, and Patient-Reported Outcomes Measurement Information System-10 to measure global physical and mental health preoperatively and 1 year postoperatively.

RESULTS

Preoperatively, 22% and 15% of patients demonstrated major and mild depression, respectively. High resilience was identified in 34% of patients, normal resilience in 55%, and low resilience in 11%. Preoperative depression correlated with lower resilience, global physical health, and global mental health scores preoperatively as well as at 1 year after surgery (P < .001). Higher levels of preoperative resilience correlated with higher global physical and mental health scores preoperatively and at 1 year postoperatively (P < .001).

CONCLUSION

Depression symptoms are common among patients undergoing primary TJA and are associated with worse patient-reported outcomes. Patients with higher levels of resilience have higher global physical and mental health scores before and after TJA. Psychological traits and depression impact clinical outcomes following TJA.

Factors that influence inpatient satisfaction after shoulder arthroplasty

BACKGROUND

It is important to distinguish satisfaction regarding the outcome of care and satisfaction with the delivery of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are modern assessments of hospitals and providers of delivery of care. The purpose of this study was to report inpatient satisfaction according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) scores after shoulder arthroplasty and to determine factors that influence them, as well as their correlation with surgical expectations, pain perception, quality of life, surgical setting, and functional outcomes.

METHODS

All patients scheduled for a shoulder arthroplasty were prospectively asked to complete a demographic and initial shoulder assessment form, a shoulder surgery expectations survey, a pain catastrophizing scale, the SF-12 (12-item Short Form) survey, and a resiliency form (Resilience Scale 11). Patient satisfaction was measured with the CG-CAHPS and HCAHPS surveys. Legacy forms, patient-specific factors, type of surgery performed, location of surgery, length of hospital stay, and discharge disposition were evaluated on their ability to predict these survey scores. Linear regression was used to calculate correlations and predictions of continuous variables, and logistic regression was used to compared the satisfied vs. unsatisfied cohorts.

RESULTS

The average HCAHPS and CG-CAHPS satisfaction scores for the population were 74.7 ± 20.7 and 82.1 ± 19.4, respectively. Nonsmokers had a mean HCAHPS score of 77.7 ± 22.0, whereas current smokers reported a mean of 59.6 ± 5.2 (P = .03). Patients who were discharged home had a mean HCAHPS score of 77.3 ± 21.9, whereas those discharged to a skilled nursing facility reported a mean of 59.3 ± 6.6 (P = .05). These same groups also had significantly higher odds of being satisfied with the hospital. No significant differences or higher odds were seen for comparisons between overall CG-CAHPS satisfaction and any of the patient-specific factors tested. There was no significant correlation between age, length of stay, pain (pain catastrophizing scale), resiliency (Resilience Scale 11), expectations (shoulder surgery expectations survey), or function (SF-12) and both the HCAHPS and CG-CAHPS satisfaction scores.

CONCLUSION

Overall, 37 patients (74%) had CG-CAHPS scores that indicated satisfaction and 34 patients (68%) had HCAHPS scores that indicated satisfaction. Nonsmokers and patients discharged home after surgery report higher levels of inpatient hospital (HCAHPS) satisfaction after shoulder arthroplasty. Patients with high preoperative surgical expectations, pain perception, and resiliency are not generally more satisfied with the hospital or clinician. Preoperative diagnosis, location of surgery, and length of stay do not reliably impact satisfaction with the hospital or clinician. Inpatient HCAHPS and CG-CAHPS satisfaction does not correlate with legacy functional outcome measures and, therefore, may not be predictive of long-term functional outcomes.

Higher patient knowledge and resilience improve the functional outcome of primary total knee arthroplasty

BACKGROUND

A significant percentage of patients have an unfavorable outcome following primary total knee arthroplasty (TKA). This study aimed to evaluate whether specific knowledge about the implant and resilience can influence the functional outcome following TKA.

METHODS

A consecutive series of 163 patients following primary TKA at a mean age of 70 years (SD 9.1 years) were included at a regional rehabilitation center between December 2015 and December 2016. Specific patient knowledge (scale 0-7), Connor Davidson Resilience Scale (CD-RISC), Western Ontario and McMaster Universities (WOMAC) score, University of California and Los Angeles (UCLA) score and constitutional parameters were assessed on admission. Pearson's correlation analysis and stepwise linear regression analysis were performed to investigate associations between knowledge, resilience and functional scores.

RESULTS

The mean overall knowledge score was 3.5 out of 7 and the mean resilience score was 72.9 out of 100. Mean WOMAC and UCLA scores on admission were 23.8 and 5.5, respectively. Stepwise linear regression analysis identified knowledge and age as significant predictors of WOMAC scores (R² = 14.3%, p = 0.003). Knowledge and resilience were identified as significant predictors of UCLA scores (R² = 13.8%, p = 0.013).

CONCLUSION

This study highlights the importance of patient-related factors as part of an integral patient care concept in TKA. Although the identified predictors still need to be refined, it could be demonstrated how better patient knowledge might ultimately lead to better functional outcome following TKA. Routinely assessing patients' resilience might be a useful tool to identify patients at risk for low activity levels.

LEVEL OF EVIDENCE

III. Patient-reported outcome study.

Resilience in the Orthopaedic Patient

➤

Resilience is a dynamic psychological construct that refers to the ability to adapt and improve when facing adversity or other stressors.

➤

Recent investigations in various orthopaedic subspecialties have demonstrated that resilience may contribute to favorable mental health and physical function after a surgical procedure.

➤

More research, using well-designed prospective studies, is necessary to better define the role that resilience and other factors play in the health and outcomes of patients with orthopaedic conditions.

➤

Orthopaedic surgeons can consider incorporating resilience assessments into their practices to aid in identifying patients who will do well with a surgical procedure and those who may benefit from specialized therapy to optimize their health and function.

Bouncing back after lumbar spine surgery: early postoperative resilience is associated with 12-month physical function, pain interference, social participation, and disability

BACKGROUND CONTEXT

Positive psychosocial factors early after surgery, such as resilience and self-efficacy, may be important characteristics for informing individualized postoperative care.

PURPOSE

To examine the association of early postoperative resilience and self-efficacy on 12-month physical function, pain interference, social participation, disability, pain intensity, and physical activity after lumbar spine surgery.

STUDY DESIGN/SETTING

Pooled secondary analysis of prospectively collected trial data from two academic medical centers.

PATIENT SAMPLE

Two hundred and forty-eight patients who underwent laminectomy with or without fusion for a degenerative lumbar condition.

OUTCOME MEASURES

Physical function, pain inference, and social participation (ability to participate in social roles and activities) were measured using the Patient Reported Outcomes Measurement Information System. The Oswestry Disability Index, Numeric Rating Scale, and accelerometer activity counts were used to measure disability, pain intensity, and physical activity, respectively.

METHODS

Participants completed validated outcome questionnaires at 6 weeks (baseline) and 12 months after surgery. Baseline positive psychosocial factors included resilience (Brief Resilience Scale) and self-efficacy (Pain Self-Efficacy Questionnaire). Multivariable linear regression analyses were used to assess the associations between early postoperative psychosocial factors and 12-month outcomes adjusting for age, sex, study site, randomized group, fusion status, fear of movement (Tampa Scale for Kinesiophobia), and outcome score at baseline. This study was funded by Patient-Centered Outcomes Research Institute and Foundation for Physical Therapy Research. There are no conflicts of interest.

RESULTS

Resilience at 6 weeks after surgery was associated with 12-month physical function (unstandardized beta=1.85 [95% confidence interval [CI]: 0.29; 3.40]), pain interference (unstandardized beta=-1.80 [95% CI: -3.48; -0.12]), social participation (unstandardized beta=2.69 [95% CI: 0.97; 4.41]), and disability (unstandardized beta=-3.03 [95% CI: -6.04; -0.02]). Self-efficacy was associated with 12-month disability (unstandardized beta=-0.21 [95% CI: -0.37; -0.04].

CONCLUSIONS

Postoperative resilience and pain self-efficacy were associated with improved 12-month patient-reported outcomes after spine surgery. Future work should consider how early postoperative screening for positive psychosocial characteristics can enhance risk stratification and targeted rehabilitation management in patients undergoing spine surgery.

Evolving Outcome Measures in Total Knee Arthroplasty: Trends and Utilization Rates Over the Past 15 Years

BACKGROUND

Patient-reported outcome metrics and reporting are important for demonstrating value associated with total knee arthroplasty (TKA). This review studied the patient-reported outcome utilization trends as reported within the TKA literature over a 15-year period.

METHODS

A PubMed search of all manuscripts related to TKA from January 2005 to December 2019 was performed. Descriptive statistics were used for individual outcome metrics as proportions of total article publications focusing on TKA outcomes. Linear regressions analysis was performed to demonstrate significant changes in utilization rates over time.

RESULTS

There was a significant overall increase in studies utilizing outcome metrics between 2005 and 2019 (16.1%-45.0%; P < .001; R² = 98.7%). Within joint-specific metrics (2005-2019), use of Knee Disability and Osteoarthritis Outcome score increased (0%-14.8%; P < .001); while use of Knee Society Knee Scoring System decreased (55.2%-35.4%; P = .007). Of the studies reporting general health, use of the Forgotten Joint Score-12 decreased (100%-66.7% from 2014 to 2019; P = .006), and Patient-Reported Outcome Measurement Information System Global-10 increased (0%-21.4% from 2005 to 2019; P < .001). In the quality of life subcategory (2005-2019), EuroQol 5-Dimension Health Outcome Survey increased in usage (14.3%-28.0%; P < .001), while Short Form-36 use decreased (85.7%-36.6%; P < .001).

CONCLUSION

Although utilization of outcome metrics has significantly increased over the last 15 years in the TKA literature, there still exists considerable heterogeneity of outcome metrics. This lack of consensus may impede comparisons of studies for clinical and research purposes, as well as hinder cross-walk of outcome tools over time. Further study is needed to identify ideal global and joint-specific tools, while balancing issues like ease of use and utility in specific populations such as the young and highly active.

The Psychology of Total Joint Arthroplasty

Patient dissatisfaction after total joint arthroplasty can be as high as 20%. There are many factors that lead to dissatisfaction including unmet expectations, persistent pain, and technical errors. There is increasing evidence that psychological factors play a role in a patient's ability to manage with the surgical stress of total joint arthroplasty. These factors play an important role in dissatisfaction after surgery. In addition, there are several studies that demonstrate certain psychological factors such as resiliency can affect patient outcomes. This symposium explores the impact of these psychological factors on total joint arthroplasty with a specific focus on identification and modification of these factors.