The Impact of Preoperative Mental Health and Depression on Outcomes After Total Ankle Arthroplasty

Risk Stratification in Orthopaedic Surgery: An Important Adjustment for Value-Based Health Care and Quality Measurement

➢ Risk stratification in orthopaedic surgery is complex and depends on the outcome of interest and multiple interdependent factors. Effective risk stratification has uses for limiting and predicting adverse events in patients undergoing discretionary surgery, avoiding the penalization of surgeons for operating on candidates whose health is situated in more difficult circumstances, and ensuring that inordinate attention is not placed on discrete musculoskeletal pathophysiology when there are other pressing health priorities.➢ For individual patient decision-making, no comprehensive risk-stratification tool currently exists, in part due to the heterogeneity of orthopaedic procedures performed and the diverse patient population treated. The Elixhauser Comorbidity Measure and the Risk Stratification Index 3.0 appear to be most promising.➢ At a population level, risk stratification may be useful in alternative payment models to ensure that hospitals that treat a disproportionate number of high-risk patients are not penalized and that cherry-picking (preferentially selecting only healthier patients with a lower risk of complications) does not occur. Any attempt to risk-stratify may have unintended consequences.➢ Orthopaedic surgeons must be aware of the tools available, their strengths, and their limitations in order to be included in decision-making as payment models and public health policies are implemented.

Impact of psychological factors on the final clinical outcomes of patients undergoing ankle arthrodesis and ankle replacement

Objective

This study aims to analyze the impact of different surgical procedures on the prognosis and psychological state of patients with end-stage ankle arthritis (ESAA) by comparing two groups of patients with ESAA who have undergone total ankle replacement (TAR) and ankle arthrodesis (AA), and to investigate whether preoperative psychological status can alter the final clinical outcomes.

Methods

This study retrospectively collected data from 66 patients with ESAA who underwent AA surgery in the Foot and Ankle Surgery Department of Xi'an Honghui Hospital between 2016 and 2023. In July 2024, the final follow-up of patients was conducted via telephone or WeChat, with a follow-up duration of no less than 12 months. Before surgery and at the final follow-up, evaluations were conducted using the Chinese version of the Hospital Anxiety and Depression Scale (HADS), the Visual Analogue Scale (VAS) for pain (ranging from 0 to 100mm), and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. The study compared differences in pain scores, functional scores, and psychological scores between patients in the TAR and AA groups before surgery and at the final follow-up. Additionally, patients who underwent TAR and AA were further subgrouped based on the severity of their preoperative psychological status, in order to analyze the impact of preoperative psychological conditions on surgical prognosis.

Results

A total of 66 patients with ESAA completed the follow-up. At the final follow-up, both the VAS and AOFAS scores in the TAR group and the AA group showed significant improvement compared to preoperative levels. Among them, the TAR group performed better in terms of AOFAS scores, but no significant difference was observed in VAS scores between the two groups. Additionally, there was no significant difference in HADS scores between the two groups at the final follow-up. Regardless of whether they belonged to the high-HADS group or the low-HADS group, patients showed significant improvement in clinical scores compared to preoperative levels. However, at the final follow-up, the clinical scores of the high-HADS group were significantly lower than those of the low-HADS group, and the incidence of complications in the high-HADS group was also higher.

Conclusion

This study found that both TAR and AA significantly improved patients' psychology, pain, and functional activities. Both surgical methods demonstrated similar improvements in terms of final psychological status and pain relief. However, patients in the TAR group showed better ankle function and mobility. Patients with poorer preoperative psychological status had worse clinical outcomes and faced a higher risk of complications. The study indicates that both TAR and AA are effective treatment options for patients with ESAA, but poor preoperative psychological status is one of the important risk factors for poor prognosis. Therefore, when selecting a treatment approach, the patient's psychological state and needs should be fully considered, and necessary psychological interventions and postoperative rehabilitation plans should be implemented to enhance the patient's treatment outcomes and quality of life.

Outcomes of cobalt-chrome 3D-printed total talus replacement with and without combined total ankle replacement

BACKGROUND

Collapse of the talus and peri-talar arthritis pose treatment challenges due to the anatomy and location of the talus as a keystone of the foot and ankle. Custom 3D-printed total talus replacement (TTR) and combined total ankle total talus replacement (TATTR) have emerged as treatment options for these pathologies. However, the safety and efficacy of these implants is unknown due to the limited number of cases and short follow-up durations.

METHODS

This was a retrospective study to assess surgical outcomes of patients who underwent a TTR and TATTR with or without subtalar fusion. Patient demographics, intraoperative parameters, device related surgical and non-surgical events, imaging and clinical evaluations, and patient reported outcome (PRO) measures were compiled.

RESULTS

A total of 38 patients received a custom 3D-printed implant with mean follow-up time of 22.1 (range: 12-45) months. In this cohort, 7 (18.4 %) required secondary surgery and 3 (7.9 %) required implant removal. Multivariate logistic regression revealed that patient diagnosis of depression was a significant predictor of secondary surgery with an OR 17.50 (p = 0.037). Significant postoperative improvements were observed in the talocalcaneal height (p = 0.005) and talar declination angle (p = 0.013) for the TATTR group. VAS and PROMIS pain interference (PI) scores demonstrated an initial significant improvement in pain, but this improvement did not maintain significance at most recent follow-up. However, there was a significant increase in the PROMIS physical function (PF) scores (p = 0.037) at most recent follow-up.

CONCLUSION

These results demonstrate that TTR and TATTR provide significant improvement in post-operative radiographic foot and ankle alignment and physical function at the two-year timepoint. PRO findings suggest that patients are more active after surgery. Surgeons considering proceeding with either of these procedures should counsel patients about pain and functional outcomes as well as realistic expectations in patients with depression.

LEVEL OF EVIDENCE

Level 3.

Preoperative Acute Depressive Episodes Are Associated With Increased Medication Prescribing and Inpatient Services After Primary Arthroscopic Rotator Cuff Repair

PURPOSE

To compare postoperative health care use, prescriptions, and shoulder surgery between patients with an acute depressive episode (ADE) and those without an acute depressive episode (NADE) within 3 months before arthroscopic rotator cuff repair.

METHODS

Diagnostic and procedural codes were used to identify patients in the TriNetX Research Network at least 18 years of age and underwent arthroscopic rotator cuff repair between January 2010 and November 2021. Patients with a previous rotator cuff repair or diagnosis of recurrent major depressive disorder were excluded. Patients were stratified into ADE and NADE cohorts and propensity matched. Outcomes were measured by health care use and medication prescribing up to 3 months and incidence of future shoulder surgery up to 2 years postoperatively.

RESULTS

After propensity matching, the ADE cohort included 1,514 patients and were compared with 1,514 patients in the NADE cohort. Preoperative characteristics were similar including female sex (62.1% and 63.0%, respectively, P = .599). A greater percentage of the ADE cohort received inpatient services within 3 months (4.5% vs 3.0%, odds ratio [OR] 1.54; confidence interval [CI] 1.05-2.25, P = .027) after surgery. Patients with ADE were prescribed a greater percentage of antidepressants (32.8% vs 24.4%, OR 1.51, 95% CI 1.29-1.77, P < .0001), sedatives (25.2% vs 20.5%, OR 1.31, CI 1.11-1.55, P = .002), and opioid analgesics (63.4% vs 55.7%, OR 1.38 CI 1.19-1.59, P < .0001) within 3 months. Within 2 years, incidence of future surgery were similar for arthroscopy (7.9% vs 7.3%) and arthroplasty (2.2% vs 1.6%).

CONCLUSIONS

Acute depressive episodes before primary arthroscopic rotator cuff repair are associated with increased use of inpatient services and postoperative analgesic prescriptions. Incidence of future shoulder surgery for arthroscopy and arthroplasty was similar between patients with or without ADEs.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Preoperative anxiety and depression are associated with poorer patient-reported outcomes following total ankle replacements

INTRODUCTION

It is unclear how pre-operative anxiety/depression affects patient reported outcome measures (PROMs) following total ankle replacements (TAR). We investigated the effects of anxiety/depression on PROMs using the Manchester-Oxford Foot Questionnaire (MOXFQ) following TAR.

METHODS

PROMs data for primary TAR patients between 2011 and 2022 were extracted from a single-centre regional registry. Anxiety/depression was self-reported using the EuroQol 5-deminion (EQ-5D-3L) questionnaire. MOXFQ was applied pre-operatively and ≥ 6-months post-operatively.

RESULTS

We included 98 TARs with mean follow-up of 2.1 ± 2.0 years. 35(35.7 %) patients reported anxiety/depression pre-operatively. Significant difference between pre-operative MOXFQ-index for the anxiety/depression group (83.8 ± 12.9) and the control group (71.8 ± 12.7, p < 0.001) persisted post-operatively (40.8 ± 30.1, 25.7 ± 24.6, p = 0.008). Both groups experienced significant improvement in MOXFQ-index post-operatively (p < 0.001). Overall improvement was similar between groups after adjustment for confounders (p = 0.42).

CONCLUSION

PROMs are modulated by baseline mental health after TAR. However, both groups report similar post-operative improvement.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

The impact of mental health disorders on outcomes following total ankle arthroplasty: A systematic review

BACKGROUND

The purpose of this systematic review was to evaluate the impact of mental health disorders (MHDs) on the clinical and functional outcomes following total ankle arthroplasty (TAA) for the treatment of end-stage ankle arthritis.

METHODS

A systematic review of the EMBASE, MEDLINE, and Cochrane Library databases was conducted in April 2024 following PRISMA guidelines. Data collected included patient demographics, clinical outcomes, complications, and failures.

RESULTS

Six studies published between 2019 and 2023 were included, involving a total of 8772 patients who underwent TAA. Among these, 1076 patients (12.3 %) had a pre-operative MHD. The weighted mean age was 64.1 ± 4.9 years, and the mean postoperative follow-up was 4.6 ± 7.2 months. There were inferior subjective clinical outcomes in patients with an associated MHD, as demonstrated by lower scores in the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), Visual Analogue Scale (VAS), and American Orthopaedic Foot and Ankle Society (AOFAS) scores compared to patients without a MHD. Additionally, patients with MHDs had high complication rates (23.7 %), including 76 prosthetic complications (6.1 %) and 15 cases (1.2 %) requiring revision procedures. However, no significant differences in objective outcomes such as joint mobility or implant failure rates were found between those with and without MHDs.

CONCLUSION

MHDs adversely affect subjective outcomes and complications following TAA, highlighting the need for integrated mental health management in preoperative and postoperative care. Further research is needed to understand the precise role of mental health in TAA outcomes.

The Influence of Resilience on Outcomes After Total Ankle Arthroplasty

BACKGROUND

Resiliency is the ability to recover from stressful events and has been shown to correlate with patient outcomes following certain orthopaedic procedures. The purpose of this study was to determine the relationship between resiliency and outcomes following TAA.

METHODS

A retrospective analysis of patients undergoing primary TAA between April 2015 and September 2022 was performed (N = 83). Data included demographics, comorbidities, complications, preoperative and postoperative visual analog scale (VAS) pain and Foot and Ankle Ability Measure (FAAM) functional scores, Brief Resilience Scale (BRS) scores, and surgical satisfaction. Patients were defined as having low resilience (LR), normal resilience (NR), or high resilience (HR) based on a BRS score of <3, 3-4.30, and >4.3, respectively.

RESULTS

High resilience patients had significantly higher postoperative FAAM ADL, Sports, and Overall scores as well as a significantly greater increase from preoperative scores compared with LR and NR patients. Low resilience patients had significantly lower FAAM Sports and Overall scores compared with normal and high resilience patients. BRS scores positively correlated with postoperative FAAM scores. We found no difference in satisfaction or VAS between the 3 cohorts. Multivariate regression analysis identified BRS scores to be an independent predictor for greater changes in FAAM scores following TAA.

CONCLUSION

Although functional improvements following TAA are expected, patients with higher resilience at baseline are more likely to experience greater improvements in functional outcomes following surgery.

LEVEL OF EVIDENCE

Level III.

What does routine depression screening in the ambulatory orthopedic clinic teach us? Results from nearly 60,000 patient encounters

Background

It remains unclear what role depression screening plays in routine ambulatory orthopedic care. The purpose of this study was to determine (1) the floor and ceiling effects of the Patient-Reported Outcomes Measurement Information System Depression (PROMIS-D) form, (2) the prevalence of positive PROMIS-D screening forms across an orthopedic service line, and (3) the prevalence of previously diagnosed depression and interventions among a representative sample of patients.

Methods

This retrospective study analyzed 58,227 patients who presented to ambulatory orthopedic clinics across an orthopedic service line between January 1, 2019 to December 31, 2021. All patients completed a self-administered PROMIS-D form as part of the ambulatory encounter. Scores were analyzed with respect to patient characteristics including age, gender, and presenting orthopedic complaint. A sample of 1000 patients was evaluated for prevalence of depressive symptoms and formal psychiatric diagnosis and interventions in the 5 years preceding the clinic visit.

Results

PROMIS-D displayed a negligible ceiling effect (<0.001 %) but a large floor effect (19.0 %). PROMIS-D scores indicating depressive symptoms were highest among patients presenting with spine complaints (42.8 %) and lowest among patients presenting to orthopedic pediatric clinics (28.6 %). Women and those in the lowest quartile median household income (MHI) were more likely to report depressive symptoms. Among the 1000 patient sample, 31.3 % exhibited depressive symptoms. Of these, 39 % had previously received some form of mental health treatment, including 33.2 % who were prescribed antidepressants.

Conclusions

PROMIS-D is a useful screening questionnaire for patients in the orthopedic clinic, although there is a consistent floor effect. There are a number of patients who present to the orthopedic clinic who have depressive symptoms but have had no interaction with behavioral health. Given the impact depression can have on outcomes, screening for depressive symptoms should be considered as part of routine orthopedic practice.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

Influence of health literacy on health-related quality of life after total hip arthroplasty

INTRODUCTION

Personal knowledge about the own disease, a key component of health literacy (HL), may have a considerable impact on treatment outcomes. The purpose of this study was to investigate whether the patients' knowledge about the surgical procedure, risks, and aftercare, as well as the satisfaction with the preoperative level of information, has an influence on the health-related quality of life (HRQoL) after primary total hip arthroplasty (THA).

MATERIALS AND METHODS

A total of 176 patients (68.3 ± 10.3 years, 60.8% female) were evaluated. HRQoL was assessed prior to surgery as well as one and twelve months after THA using the 12-item Short Form Questionnaire. Following standardized surgical informed consent, HL was assessed preoperatively using a self-constructed quiz score, while information satisfaction was measured with a single-item rating scale. Sociodemographic and clinical characteristics, including pain (VAS), functionality (WOMAC), and psychological distress (PHQ-4), were also assessed at baseline. Multiple linear regression analyses were performed to examine whether HL, satisfaction with information, age, social class, WOMAC, VAS, and PHQ-4 predict HRQoL at one and twelve months post-surgery.

RESULTS

The average HL quiz score was 23 ± 5.1 out of a possible 33 points. Social class index significantly influenced HL (p < 0.001). A weak correlation between HL and age (r = 0.23, p = 0.01) and no correlation between HL and psychological distress (p = 0.868) were observed. One month after THA, physical HRQoL was significantly predicted by the WOMAC index (p = 0.031) and subjective satisfaction with information (p = 0.022), but not by HL. After twelve months, only the WOMAC was a significant predictor (p < 0.001) of physical HRQoL.

CONCLUSION

Although subjective satisfaction with the patient's preoperative level of information had a significant effect on the physical HRQoL at one month after THA, the influence of osteoarthritis severity outweighed this effect after twelve months. HL had no direct influence on HRQoL. These results suggest that patient satisfaction, rather than knowledge, predicts HRQoL.

Learning curve of total ankle arthroplasty: a systematic review

INTRODUCTION

Together with ankle arthrodesis, total ankle arthroplasty is now accepted as a first-line intervention in the management of end-stage arthritis of the ankle. The evidence regarding how outcomes are affected by surgeon experience is inconsistent; we performed a systematic review to evaluate the effect of a learning curve in total ankle arthroplasty outcomes.

METHODS

An electronic database search was performed in PubMed, Embase, ISI Web of Science and Cochrane trials. Two reviewers independently conducted a two-stage title/abstract and full text screening. English-language original research studies comparing patient-reported outcome measures (PROMs), complication/revision rates, operative time, length of stay or radiation exposure according to surgeon experience were included. Quality assessment was performed using the methodological index for non-randomised studies.

RESULTS

All but one included study report either improved PROMs, reduced complication/revision rate, reduced hospital stay length/operative time or reduced radiation exposure with increasing surgeon experience. However, the majority of these findings lack statistical significance. Two studies assessing the plateau of the learning curve report a wide range of plateau thresholds between 9 and 39 cases.

CONCLUSION

This review finds a largely non-significant trend towards improvements in PROMs, complication, and revision rates with improved surgeon experience. The lack of statistical significance in a number of studies may be partially explained by methodological flaws, with more suitably designed studies reporting significant improvements. Future research into the effect of advancements in implant design and insertion guides is required to further characterise the magnitude of the learning curve and guide both mitigation and learning strategies.

Association of Preoperative Depression Score With Outcomes of Transfibular Total Ankle Arthroplasty

Favorable short-term results of transfibular total ankle arthroplasty have been reported in several studies; however, the factors affecting these results have not been elucidated. This study aimed to determine whether preoperative depression affects the outcome of transfibular total ankle arthroplasty and whether depression changes with surgery. Scores from the Japanese Society of Surgery of the Foot Ankle/Hindfoot scale (JSSF scale), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), Hospital Anxiety and Depression Scale (HADS), and Timed Up & Go test (TUG) were collected preoperatively, at 6 months, and at 1 year postoperatively from 20 patients. Eighteen patients were diagnosed with osteoarthritis and 2 patients with rheumatoid arthritis. The mean age of the patients was 75 years. Patients were divided into 2 groups: those with preoperative HADS depression scores above the median (higher depression score group) and below the median (lower depression score group), and intergroup comparisons were made. No significant differences were observed in the JSSF and TUG scores between the groups, both preoperatively and postoperatively. Meanwhile, the SAFE-Q pain subscale score was significantly lower in the higher depression score group than in the lower depression score group (median, 59 vs 90) 1 year postoperatively. There were no differences in the other SAFE-Q subscale scores between the groups. The results suggested that depressive tendencies did not affect postoperative functional results using objective assessment measures but had a negative impact on pain in subjective assessment measures.

Team Approach: Management of Mental Health in Orthopaedic Patients

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Mental health evaluation should be considered an essential part of the routine preoperative assessment and should be managed by a multidisciplinary team composed of the primary care physician, orthopaedic provider, and behavioral health specialist.

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The scientific literature indicates that patients without comorbid psychiatric symptoms and adaptive coping strategies, resilience, and well-managed expectations have improved functional outcomes and satisfaction after orthopaedic procedures.

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Psychological issues are multifaceted and require treatment tailored to each individual patient. Therefore, close communication between all members of the care team is required to create and execute the perioperative plan.

Total Ankle Replacement Provides Symmetrical Postoperative Kinematics: A Biplane Fluoroscopy Imaging Study

BACKGROUND

In vivo measurements of tibiotalar and subtalar joint motion following TAR are unavailable. Using biplane fluoroscopy, we tested the hypothesis that the prosthetic tibiotalar joint and adjacent subtalar joint would demonstrate kinematic and range of motion differences compared to the contralateral untreated limb, and control participants.

METHODS

Six patients of 41 identified candidates that all underwent unilateral Zimmer TAR (5.4 ± 1.9 years prior) and 6 control participants were imaged with biplane fluoroscopy during overground walking and a double heel-rise activity. Computed tomography scans were acquired; images were segmented and processed to serve as input for model-based tracking of the biplane fluoroscopy data. Measurements included tibiotalar and subtalar kinematics for the TAR, untreated contralateral, and control limbs. Statistical parametric mapping quantified differences in kinematics throughout overground walking and the double heel-rise activity.

RESULTS

Patients with this TAR performed walking and heel-rise activities symmetrically with no significant kinematic differences at the tibiotalar and subtalar joints between limbs. Compared to control participants, patients exhibited reduced dorsi/plantarflexion range of motion that corresponded to decreased peak dorsiflexion, but only in the late stance phase of walking. This reduction in tibiotalar dorsi/plantarflexion range of motion in the TAR group became more apparent with double heel-rise activity.

CONCLUSION

Patients with a Zimmer TAR had symmetric kinematics during activities of walking and double heel-rise, but they did exhibit minor compensations in tibiotalar kinematics as compared to controls.

CLINICAL RELEVANCE

The lack of significant kinematic compensation at the subtalar joint may explain why secondary subtalar osteoarthritis is reported as being relatively uncommon in patients with some TAR designs.

Long-Term Survival of HINTEGRA Total Ankle Replacement in 683 Patients: A Concise 20-Year Follow-up of a Previous Report

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Psychological Health on Patient Recovery After Arthroplasty

PURPOSE

The purpose of this study was to determine the relationship between psychological health and postoperative recovery and satisfaction in patients undergoing total joint arthroplasty (TJA).

METHODS

We prospectively enrolled patients undergoing TJA from July 2019 to December 2020. A psychological evaluation was conducted according to the Hospital Anxiety and Depression Scale (HADS). Based on the preoperative HADS scores, we grouped the patients into two groups: the symptomatic group and the asymptomatic group. Data on the Harris Hip Score (HHS), Knee Society Knee Scoring System (KSS), Forgotten Joint Score-12 (FJS-12), Short Form-12 (SF-12), and Numeric Rating Scale (NRS) for pain in these two groups were collected preoperatively and postoperatively. Then, these data were analyzed by Statistical Package for Social Sciences (SPSS) version 19.

RESULTS

The final cohort consisted of 80 patients. Patients undergoing TJA had significantly decreased HADS and NRS scores and improved HHS, KSS, SF-12, and FJS-12 scores (all p < 0.001). Compared with the symptomatic group, the asymptomatic group showed better postoperative recovery (p < 0.05), especially after total knee arthroplasty (TKA) (p < 0.05). Good postoperative recovery positively impacted the patients' postoperative psychological state.

CONCLUSION

Finally, the psychological state can affect recovery after TJA, and successful TJA can help improve patients' psychological states, especially after TKA.

Depression Following Operative Treatments for Achilles Ruptures and Ankle Fractures

BACKGROUND

The sudden and debilitating nature of lower extremity injuries can trigger mood disturbances, including major depressive disorder.

METHODS

This prospective study enrolled patients undergoing operative repair of ankle fractures and Achilles ruptures and followed them for 1 year postoperatively. The validated Patient Health Questionnaire (PHQ-9) for depressive symptoms was administered at the preoperative visit and at postoperative weeks 1, 2, 4, 8, 16, 24, 32, 40, and 52. PHQ-9 is scored 0 to 27, with higher values indicating greater depression symptoms.

RESULTS

Fifty-eight patients completed 1 year of follow-up. The mean PHQ-9 score was 2.7 (range, 0-20) at the preoperative visit, peaked at postoperative week 1 (4.9; range, 0-16), and reached its low at postoperative week 52 (0.8; range, 0-7). Cumulative incidences of depressive symptoms during the first year following surgery were 51.7% for at least mild depression, 22.4% for at least moderate depression, and 6.9% for severe depression. A history of mental health disorder and the inability to work during the period of postoperative immobilization were independently associated with greater depressive symptoms.

CONCLUSION

The majority of patients undergoing operative treatment of Achilles ruptures and ankle fractures develop postoperative symptoms of mild to moderate depression that normalize after several months. Patients with a history of mental health disorder or who cannot work while immobilized postoperatively are at greatest risk.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Prospective Cohort Study to Investigate Factors Associated With Continued Immobilization of a Nondisplaced Scaphoid Waist Fracture

PURPOSE

The decision to continue immobilization of a nondisplaced scaphoid waist fracture is often based on radiographic appearance (despite evidence that radiographs are unreliable and inaccurate for diagnosing scaphoid union 6-12 weeks after fracture) and fracture tenderness (even though it is influenced by cognitive biases on pain). This may result in unhelpful additional immobilization. We studied nondisplaced scaphoid waist fractures to determine the factors associated with (1) the surgeon's decision to continue cast or splint immobilization at the first visit when cast removal was being considered; (2) greater pain on examination; and (3) the surgeon's concern about radiographic consolidation.

METHODS

We prospectively included 46 patients with a nondisplaced scaphoid waist fracture treated nonoperatively. At the first visit when cast removal was considered - after an average of 6 weeks of immobilization - patients rated pain during 4 examination maneuvers. The treating surgeon assessed union on radiographs and decided whether to continue or discontinue immobilization. Patients completed measures of the following: (1) the degree to which pain limits activities (Patient-Reported Outcome Measure Interactive System [PROMIS] Pain Interference Computer Adaptive Test [CAT], Pain Self-Efficacy Questionnaire-2); (2) symptoms of depression (PROMIS Depression CAT); and (3) upper extremity function (PROMIS Upper Extremity Function CAT). We used multivariable regression analysis to investigate the factors associated with each outcome.

RESULTS

Perceived inadequate radiographic healing and greater symptoms of depression were independently associated with continued immobilization. Pain during the examination was not associated with continued immobilization. Patient age was associated with pain on examination. Shorter immobilization duration was the only factor associated with the surgeon's perception of inadequate radiographic consolidation.

CONCLUSIONS

Inadequate radiographic healing and greater symptoms of depression are associated with a surgeon's decision to continue cast or splint immobilization of a nondisplaced scaphoid waist fracture.

CLINICAL RELEVANCE

Overreliance on radiographs and inadequate accounting for psychological distress may hinder the adoption of shorter immobilization times for nondisplaced waist fractures.