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

The Impact of Anxiety and Depression on Postoperative Pain Management and Emergency Room Visits in Pediatric Patients With Surgically Treated Lower Extremity Fractures: A Propensity-matched Cohort Analysis

BACKGROUND

Anxiety and depression (AD) are prevalent comorbidities in pediatric patients and may influence postoperative outcomes. The impact of AD on postoperative pain medication use and emergency room (ER) visits in children with surgically treated lower extremity fractures has not been well-documented. This study aimed to evaluate the association between AD and outpatient postoperative pain medication requirements as well as ER visits in this population.

METHODS

A retrospective cohort study was conducted using electronic medical records from 2000 to 2023 in a large national database of health care organizations across the United States. Pediatric patients (age below 18) with surgically treated lower extremity fractures were included. Patients were categorized into 2 groups: those with AD and those without (No-AD). Patients were further dichotomized into 2 groups based on fracture location: femur (femur) versus tibia or ankle (tibia/ankle). Outcomes of interest included the use of intravenous (IV) opiates within 3 days postoperatively, the number of outpatient oral (PO) opiate prescriptions, and the proportion of patients with at least one ER visit within 1 year postsurgery. Hazard ratios (HRs) were calculated using Cox proportional hazard models, adjusting for demographic and clinical characteristics.

RESULTS

A total of 25,658 patients with either femur or tibia/ankle fractures were included. After matching, 735 patients were included in the AD femur cohort, and 945 in the AD tibia/ankle cohort. Each cohort was matched 1:1 with their control counterparts. In the femur fracture cohort, 49.80% of AD patients and 46.53% of No-AD patients required IV opiates within the first 3 days after surgery (HR, 1.09; P =0.21). Outpatient PO opiate use was significantly higher in AD patients (55.78% vs. 38.50%, HR, 1.64; P <0.001). In addition, AD patients had a higher proportion of ER visits (20.3% vs. 11.7%, HR, 1.68; P <0.001). In the tibia/ankle fracture cohort, 55.2% of AD patients and 48.3% of No-AD patients required IV opiates within the first 3 days (HR, 1.18; P <0.001). Outpatient PO opiate use was also higher in AD patients (46.35% vs. 32.06%, HR, 1.55; P <0.001). ER visits were more frequent in AD patients (21.26% vs. 9.63%, HR, 2.08; P <0.001).

CONCLUSIONS

Pediatric patients with AD undergoing surgery for lower extremity fractures have increased postoperative pain medication requirements and higher rates of ER visits compared with those without AD. These findings highlight the need for targeted interventions, such as the use of preoperative counseling or multimodal pain regimens, to manage postoperative pain and reduce ER visits in this vulnerable population.

LEVEL OF EVIDENCE

Prognostic level III.

Evidence for return to work following complex orthopaedic injury - a scoping review

BACKGROUND

The rates of return to work (RTW) following complex orthopaedic injury are low. No review has summarised current knowledge and prognostic factors for RTW in these patients.

OBJECTIVES

This scoping review presents the nature and the extent of current research evidence for the prognostic factors of RTW following complex orthopaedic injury.

METHODS

This review was designed using the PRISMA-ScR checklist. Online databases were searched for articles (1969-2023) which covered: return to work, complex orthopaedic injury, and prognostic factors. Complex orthopaedic injury is defined as multiple fractures, open fractures, high energy pelvic injuries or polytrauma with related orthopaedic injury. Data were extracted and placed into an evidence table.

RESULTS

Eleven studies were eligible for inclusion. All but one were prospective cohort in design with small patient numbers. There was a skew for studies of open tibial fractures. There was limited breadth of tested prognostic factors. The only commonly reported statistically significant prognostic factors were age, ISS classification and nature of work. Endpoints for RTW ranged from 3 months to 8 years, preventing the pooling of data for meta-analyses.

CONCLUSION

In summary, there is a limited understanding of prognostic factors for RTW following complex orthopaedic injury. Estimates for RTW following these injuries range from 16-90%. The authors recommend that future studies take a holistic approach, using the biopsychosocial model, when investigating prognostic factors for RTW in these patients. This study offers guidance on qualitative investigation, investigative variables and mechanisms to achieve this.

Serotonergic Antidepressants Are Associated With Higher Rates of Hematoma After Anterior Cervical Spine Surgery: A Large Propensity-Matched Cohort Analysis

STUDY DESIGN

Large database propensity-matched retrospective cohort analysis.

OBJECTIVE

This study aimed to investigate the potential effects of serotonergic antidepressants on outcomes after anterior cervical spine surgery. It was hypothesized that the perioperative use of serotonergic antidepressants would be associated with higher rates of hematoma formation and worse outcomes after anterior cervical spine surgery.

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been associated with worse outcomes after orthopedic procedures.

MATERIALS AND METHODS

A retrospective cohort analysis was performed using TriNetX, an aggregated and de-identified electronic health record platform. Patients who underwent anterior cervical surgery were included through Current Procedural Terminology codes and the International Classification of Disease, 10th Revision, encounter diagnosis codes. Cohorts were 1:1 propensity-matched across 7 demographic and medical comorbidity parameters, and outcomes were compared. The incidence of adverse outcomes, as well as health care utilization, within 14 days, 30 days, 90 days, and 2 years postoperatively was evaluated.

RESULTS

Following propensity matching, each cohort consisted of 9249 patients, for a total of 18,498 patients included in the final statistical analysis. SSRIs/SNRIs were associated with higher odds of hematoma formation within 7 days [0.69% vs . 0.46%, odds ratio (OR): 1.5 (95% CI: 1.02-2.2), P = 0.04] and within 14 days postoperatively [0.81% vs . 0.52%, OR: 1.6 (95% CI: 1.1-2.3), P = 0.01]. Within 30 and 90 days, SSRIs/SNRIs were associated with a higher risk of emergency department utilization [30 d, OR: 1.30 (1.1-1.4); 90 d, OR: 1.3 (1.2-1.4)] and irrigation & debridement (I&D; 30 d, OR: 1.9 (1.2-3.0)]. SSRIs/SNRIs were also associated with a significantly higher risk of I&D within 2 years [OR: 1.3 (1.1-1.6)].

CONCLUSION

The use of serotonergic antidepressants perioperatively was associated with higher odds and risk of numerous outcomes, including hematoma formation, emergency department utilization, and the need for irrigation and debridement. Future prospective studies are required to confirm these results.

LEVEL OF EVIDENCE

Level III-retrospective cohort analysis.

Orthopaedic deception: when psychiatric disorders mimic musculoskeletal conditions

Psychiatric disorders significantly impact orthopaedic practice, often manifesting in ways that can complicate diagnosis and treatment. This narrative review explores psychiatric conditions that mimic musculoskeletal disorders, including Conversion Disorder, Factitious Disorder, Somatic Symptom Disorder, and Malingering. These disorders present a range of challenges, from interfering with accurate diagnosis to contributing to suboptimal clinical outcomes and increased healthcare costs. Is fundamental the role of orthopaedic surgeons in recognizing these conditions, which can present as genuine musculoskeletal symptoms but have underlying psychiatric origins. It emphasizes the need for heightened awareness and proper training to avoid misdiagnosis and ensure timely, appropriate treatment. By examining current literature, the review provides a comprehensive overview of each disorder, detailing their clinical presentations, diagnostic criteria, and treatment strategies. The aim is to enhance orthopedic practitioners' ability to identify and manage these complex cases effectively, improving patient care and reducing the risk of unnecessary interventions.

Preoperative antidepressant use in patients with depression is associated with increased complications and additional shoulder procedures following rotator cuff repair

Background

Preoperative depression has been associated with inferior functional outcomes and increased complications following arthroscopic rotator cuff repair (RCR). This study evaluated the association of antidepressant use with postoperative complications following arthroscopic RCR.

Methods

The TriNetX database was used to evaluate postoperative outcomes of patients who underwent arthroscopic RCR from February 24, 2004 to February 24, 2024. Patients diagnosed preoperatively with depression and documented antidepressant use within 1 year preceding surgery were compared to patients with preoperative depression but no history of preoperative antidepressant use. The cohorts were propensity-matched for demographic factors including age, type 2 diabetes, nicotine dependence, alcohol-related and opioid-related disorders, and indicators of depression severity (eg, suicide attempt, history of self-harm, sleep disorders). Outcomes were evaluated within 90 days and 3 years postoperative.

Results

A total of 9151 patients with documented antidepressant medication use were matched with 5894 patients with no antidepressant use. Patients using antidepressants demonstrated significantly higher odds of acute postoperative pain (P < .0001), shoulder stiffness (P = .0011), and emergency department visit (P < .0001) within 90 days postoperative and significantly increased odds of shoulder pain (P < .0001); RCR revision surgery (P < .0001); shoulder arthrocentesis, aspiration, and/or injection (P < .0001); and shoulder arthroplasty (P < .0001) within 3 years postoperative.

Conclusion

Preoperative antidepressant use was associated with significantly increased odds of acute postoperative pain, emergency department visits, opioid abuse, and additional shoulder procedures following arthroscopic RCR and did not mitigate the deleterious impact of depression on arthroscopic RCR outcomes.

Stress, Resilience, Sexual Functioning and Quality of Life in Patients Undergoing Arthroplasty and Arthroscopy

Background

In India, the incidence of orthopaedic conditions is significantly increasing, with 63 million people suffering from various orthopaedic issues, causing considerable distress to patients. This study aims to assess stress, resilience, sexual functioning, and quality of life in participants who underwent arthroplasty and arthroscopy surgery at baseline, one month, and three months.

Method

This comparative study utilised the Perceived Stress Scale (PSS), Connor-Davidson Resilience Scale, Sexual Function Scale, and the WHO Quality of Life Scale.

Results

The comparison between arthroscopy and arthroplasty reveals distinct patterns in stress, resilience, sexual functioning, and quality of life. For both procedures, stress levels were higher at baseline and one-month post-surgery but decreased by three months. Resilience scores improved consistently over time in both groups. However, sexual functioning and quality of life showed different trends: while sexual functioning initially decreased post-arthroscopy but improved by three months, arthroplasty participants generally experienced a more consistent improvement in both sexual functioning and quality of life from baseline through the follow-up periods.

Conclusion

The study showed that stress was significantly higher at baseline and one-month post-surgery. However, the trends in sexual functioning and quality of life differed between the two types of surgery. These findings highlight the need for tailored patient support and interventions based on the type of orthopaedic procedure performed.

Chronic pain for rheumatological disorders: Pathophysiology, therapeutics and evidence

Pain is the leading reason people seek orthopedic and rheumatological care. By definition, most pain can be classified as nociceptive, or pain resulting from non-neural tissue injury or potential injury, with between 15% and 50% of individuals suffering from concomitant neuropathic pain or the newest category of pain, nociplastic pain, defined as "pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, or of a disease or lesion affecting the somatosensory system." Pain classification is important because it affects treatment decisions at all levels of care. Although several instruments can assist with classifying treatment, physician designation is the reference standard. The appropriate treatment of pain should ideally involve multidisciplinary care including physical therapy, psychotherapy and integrative therapies when appropriate, and pharmacotherapy with non-steroidal anti-inflammatory drugs for acute, mechanical pain, membrane stabilizers for neuropathic and nociplastic pain, and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants for all types of pain. For nonsurgical interventions, there is evidence to support a small effect for epidural steroid injections for an intermediate-term duration, and conflicting evidence for radiofrequency ablation to provide at least 6months of benefit for facet joint pain, knee osteoarthritis, and sacroiliac joint pain. Since pain and disability represent the top reason for elective surgery, it should be reserved for patients who fail conservative interventions. Risk factors for procedural failure are the same as risk factors for conservative treatment failure and include greater disease burden, psychopathology, opioid use, central sensitization and multiple comorbid pain conditions, poorly controlled preoperative and postoperative pain, and secondary gain.

Prevalence, resources, provider insights, and outcomes: a review of patient mental health in orthopaedic trauma

This literature review examines the impact of orthopaedic trauma on patient mental health. It focuses on patient outcomes, available resources, and healthcare provider knowledge and education. Orthopaedic trauma represents a significant physical and psychological burden for patients, often resulting in long-term disability, pain, and functional limitations. Understanding the impact of orthopaedic trauma on patient mental health is crucial for improving patient care, and optimizing recovery and rehabilitation outcomes. In this review, we synthesize the findings of empirical studies over the past decade to explore the current understanding of mental health outcomes in patients with orthopaedic trauma. Through this analysis, we identify gaps in existing research, as well as potential avenues for improving patient care and mental health support for patients with severe orthopaedic injuries. Our review reveals the pressing need for collaboration between healthcare providers, mental health professionals, and social support systems to ensure comprehensive mental care for patients with traumatic orthopaedic injuries.

Assessing the validity and reliability of the 10-item Persian version of the perceived stress scale in post-surgery patients

Introduction

The 10-item Perceived Stress Scale (PSS-10) is commonly used to measure stress levels in postoperative patients, as research shows that high levels of stress can affect postoperative outcomes. By using the PSS-10, healthcare providers can understand patients' psychological well-being before and after surgery, helping improve recovery and overall health. This study focuses on assessing the reliability and validity of the 10-item Persian version of the PSS (PSS-10-P) in postoperative patients.

Methods

In a methodological study conducted between October to December 2023, a sample of 400 patients who had undergone surgery in 17 Shahrivar Hospital, Amol, Iran were selected using a convenience sampling method. The PSS-10 scale utilized in the study was translated, and its psychometric properties were evaluated through assessments of construct validity, including exploratory (n = 200) and confirmatory (n = 200) factor analysis, convergent validity, and discriminant validity. Furthermore, the study examined the internal consistency of the scale to ensure its reliability.

Results

The mean age of the participants was 44.38 (SD= 13.49) years. The results of exploratory factor analysis with Promax rotation extracted two factors accounting for 83.82% of the variance comprising 10 items. After necessary modifications during CFA, the final model was approved. As for reliability, the Cronbach's alpha, CR, and MaxR for all constructs were greater than 0.7, demonstrating good internal consistency and construct reliability.

Conclusion

According to these results, the Persian version of PSS-10 has a valid structure and acceptable reliability. This scale can be used by health professionals in many ways.

Sleep quality and psychological health in patients with pelvic and acetabulum fractures: a cross-sectional study

BACKGROUND AND OBJECTIVES

It is known that difficulty sleeping after a fracture can have negative effects on both mental and physical health and may prolong the recovery process. The objective of this study is to explore how sleep quality and psychological health are linked in patients with pelvic and acetabulum fractures.

METHODS

A study was conducted on 265 patients between 2018 and 2022 who had suffered pelvic and acetabulum fractures. The study examined various factors, including age, gender, cause of injury, post-operative complications, and injury severity. The study employed ordinal logistic regression to examine the relationship between various pelvic fractures and seven subscales of the Majeed Pelvic Score (MPS), as well as the Sleep Disorder Questionnaire (SDQ) and Beck Depression Inventory (BDI). The study focused on the postoperative outcome one year after surgery, and each patient was assessed at the one-year mark after surgical intervention. Additionally, the study evaluated the functional outcome, sleep quality, and psychological disorders of the patients.

RESULTS

From 2018 to 2022, a total of 216 patients suffered from pelvic and acetabulum fractures. Among them, 6.6% experienced borderline clinical depression, and 45.2% reported mild mood disturbances. Anxiety was found to be mild to moderate in 46% of Tile C and posterior acetabulum wall fracture patients. About 24.8% of patients reported insomnia, while 23.1% reported sleep movement disorders. However, no significant correlation was found between fracture types and sleep disorders. The mean Majeed pelvic score (MPS) was 89.68.

CONCLUSIONS

Patients with pelvic and acetabular fractures typically experience functional improvement, but may also be at increased risk for insomnia and sleep movement disorders, particularly for certain types of fractures. Psychological well-being varies between fracture groups, with signs of borderline clinical depression observed in some cases. However, anxiety levels do not appear to be significantly correlated with pelvic and acetabular fractures.