Patterns of Depressive Symptoms Before and After Surgery for Osteoarthritis: A Descriptive Study

The impact of diabetes status on pain and physical function following total joint arthroplasty for hip and knee osteoarthritis: variation by sex and body mass index

Few studies have examined diabetes impact on total joint arthroplasty (TJA) outcomes, with variable findings. We investigated the association between diabetes and post-TJA physical function and pain, examining whether diabetes impact differs by sex and BMI. Patient sample completed questionnaires within 3 months prior to hip or knee TJA for osteoarthritis (OA) and 1-year post-surgery. Surgical 'non-response' was defined as < 30% improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function at 1-year. Two adjusted logistic regression models were estimated: (1) excluding, (2) including an interaction between diabetes, sex and BMI. The sample (626 hip, 754 knee) was 54.9% female, had mean BMI of 30.1, 13.0% reported diabetes. In adjusted models excluding an interaction, diabetes was not associated with non-response. However, a significant 3-way interaction (physical function: p = 0.003; pain: p = 0.006) between diabetes, sex, and BMI was found and was associated with non-response: non-response probability increased with increasing BMI in men with diabetes, but decreased with increasing BMI in women in diabetes. Findings suggest uncertainty in diabetes impact may be due to differential impacts by sex and BMI. A simple consideration of diabetes as present vs. absent may not be sufficient, with implications for the large TJA population.

Effect of Depression Interventions in Patients Undergoing Total Joint Arthroplasty Without a Formal Diagnosis of Depression: A Systematic Review

PURPOSE

Depression is a notable contributor to suboptimal outcomes after total joint arthroplasty (TJA). We conducted a systematic review of comparative studies to review the available evidence of interventions that affected depression scores and/or outcomes for patients undergoing TJA.

METHODS

EMBASE, Ovid MEDLINE, PubMed, and Scopus were reviewed systematically from inception until November 15, 2022. Studies that were relevant for this review included comparative studies between patients who received an intervention within 3 months before or after their primary total hip or knee arthroplasty procedure. The interventions included a wide range of modalities, which were grouped into psychotherapy, enhanced perioperative support, and pharmacotherapy. Other interventions included physiotherapy techniques with a psychological focus, art/music-based therapy, occupational therapy support, and educational interventions. Meta-analysis was conducted for psychotherapy and enhanced support.

RESULTS

The final systematic review consisted of 28 relevant studies, most of which were randomized controlled trials. A total of 3,702 patients, with a mean age of 66 years, were considered, of whom 59% were female. Most of the studies reported a notable reduction in depressive symptoms and/or scores based on the interventions being analyzed. At 3 months postoperatively, psychotherapy and enhanced support both resulted in markedly better depression and function scores compared with control subjects, with psychotherapy additionally improving pain scores.

CONCLUSIONS

Overall, a wide range of interventions aimed at psychological optimization of patients undergoing TJA can improve depressive symptoms, pain, and function, even in the absence of a formal diagnosis of depression. Specifically, cognitive-based psychotherapy and enhanced perioperative support had the best evidence. Routine pharmacotherapy plays a limited role, if any, in the care of TJA. Additional efforts to develop pragmatic, evidence-based, and reproducible interventions are warranted to continue to optimize outcomes in TJA patients.

Time course and correlates of psychological distress post spinal surgery: A longitudinal study

Background

Psychological distress post lumbar spine surgery is associated with poorer outcomes. There is a scarcity of studies devoted to analyzing the risk factors associated with psychological distress in patients who have undergone lumbar fusion surgery. The purpose of this study was to (1) describe the time course and severity of psychological distress using the STarT Back Tool (SBT) and (2) determine the demographic and clinical predictors of SBT score post lumbar spine fusion surgery.

Methods

This retrospective longitudinal study analyzed 227 subjects with 1- and 2-level lumbar fusion surgery who underwent standardized assessment preoperatively and at 4 and 12 weeks postoperatively. Preoperative variables collected were demographic, clinical, and psychological variables. Postoperative psychological distress was measured by self-reported SBT. Risk factors for SBT over time were identified using ordinal and mixed-effects modelling.

Results

Although the trajectory of SBT levels declined postoperatively over time, at week-12, 20% of patients had moderate to high SBT. Postoperative SBT scores at week-4 time point was significantly greater than SBT scores at week-8 (OR = 2.7, 95% credible interval [CrI]; 1.8-3.9). Greater SBT scores at week-4 were strongly associated with greater SBT scores throughout 12 weeks of follow-up (OR = 7.3, [95% CrI; 1.2-31.4]). Greater postoperative SBT levels over time were associated with being male (OR = 2.2, 95% CrI; 1.0-3.9), greater preoperative back or leg pain intensity (OR = 2.2; 95% CrI: 1.0-4.4), greater preoperative leg weakness (OR = 4.2, 95% CrI: 1.7-7.5) and higher preoperative depression levels (OR = 4.8; 95% CrI: 1.6-10.4).

Conclusion

Postoperative SBT levels declined nonlinearly over time. However, a sizable proportion of patients had moderate to high psychological distress at week-12 postsurgery. Greater preoperative back or leg pain intensity, leg weakness and depression levels, and male gender were risk factors of greater psychological distress postsurgery. Although requiring validation, our study has identified potential modifiable risk factors which may give an opportunity to provide early (preoperative) and targeted strategies to optimize postoperative psychosocial outcomes in patients undergoing lumbar fusion surgeries.

The influence of peri-operative depressive symptoms on medium-term spine surgery outcome: a prospective study

PURPOSE

To investigate the role of depressive symptoms on clinical outcomes in patients undergoing spinal surgery up to 2-year follow-up.

METHODS

The study used data from an institutional spine surgery registry (January 2016, through March 2022) to identify patients (> 18 years) undergoing spine surgery. Patients with Oswestry Disability Index (ODI) < 20/100 at baseline or undergoing surgery on the cervical spine or for idiopathic spinal deformity and trauma patients were excluded. The patients were divided into two groups based on the pre-operative Mental Component Summary (MCS) score of the SF-36: depression group (MCS ≤ 35) or non-depression group (MCS > 35). The ODI and MCS scores trajectory were wined over the 24-month post-surgery between groups. Additionally, a secondary subgroup analysis was conducted comparing outcomes between those with depressive symptoms (persistent-depression subgroup) and those without depressive symptoms (never-depression subgroup) at 3 months after surgery.

RESULTS

A total of 2164 patients who underwent spine surgery were included. The pre-operative depression group reported higher ODI total scores and lower MCS than the pre-operative non-depression group at all time points (P < 0.001). The persistent-depression subgroup reported higher ODI total scores and lower MCS than the never-depression subgroup at all follow-ups (P < 0.001).

CONCLUSION

Functional disability and mental health status improve in patients with depression symptoms undergoing spinal surgery. Despite this improvement, they do not reach the values of non-depressed subjects. Over the 2-year follow-up time, patients with depression show a different trajectory of ODI and MCS. Caregivers should be aware of these results to counsel patients with depression symptoms.

Health, Psychological and Demographic Predictors of Depression in People with Fibromyalgia and Osteoarthritis

Depression is common in people with fibromyalgia (FM) and osteoarthritis (OA) and has been linked to adverse health outcomes in these conditions. The purpose of this study was to examine differences in predictors of depression among individuals with FM and OA using a range of health, demographic, and psychological variables. Of the total 963 participants, 600 were diagnosed with FM, and 363 with OA. The Quality of Well-Being Scale (QWB) was used to assess health status. The Fibromyalgia Impact Questionnaire (FIQ) and the Arthritis Impact Measurement Scale (AIMS) were used to measure disease-specific impact. Additionally, participants completed self-efficacy and helplessness assessments. Depression was measured using the Center for Epidemiological Studies Scale (CES-D). The results of a moderated linear regression showed that higher depression scores were associated with lower health status and a greater condition impact, especially in the FM group. Self-efficacy and helplessness predicted depression in both groups, but more strongly in FM. White participants with OA were more depressed than their non-White counterparts, while the opposite was true for FM. These findings indicate that improving health status and psychological well-being might alleviate depression in both FM and OA.

Epidemiology of Obese Patients Undergoing Revision Total Knee Arthroplasty: Understanding Demographics, Comorbidities, and Propensity Weighted Analysis of Inpatient Outcomes

INTRODUCTION

Obesity is a public health epidemic that is projected to grow in coming years. Observational data on the epidemiologic profile and immediate postoperative outcomes of obesity and morbid obesity after revision total knee arthroplasty (rTKA) are limited.

METHODS

Discharge data from the National Inpatient Sample was used to identify patients who underwent rTKA from 2006 to 2015. Patients were stratified into morbidly obese, obese, and not obese control cohorts. An analysis was performed to compare etiology of revision, demographic and medical comorbidity profiles, and immediate in-hospital economic and complication outcomes after rTKA.

RESULTS

An estimated 605,603 rTKAs were included in this analysis. Morbidly obese and obese patients were at significantly higher risk for any complication than not obese patients. Patients with obesity were associated with an increased risk of postoperative anemia but a lower risk of peripheral vascular disease and gastrointestinal, and hematoma/seroma complications compared with not obese patients. Patients with morbid obesity were associated with an increased risk of any, hematoma/seroma, wound dehiscence, postoperative infection, pulmonary embolism, and postoperative anemia complications and a lower risk of gastrointestinal complications when compared with not obese patients. Morbidly obese patients had a significantly longer length of stay than both obese and not obese patients, while no significant difference in length of stay was observed between obese and not obese patients.

DISCUSSION

Morbidly obese patients are at higher odds for worse postoperative medical and economic outcomes compared with those with obesity after rTKA. As the number of patients with obesity and morbid obesity continues to rise, these risk factors should be considered in preoperative discussions and perioperative protocol optimization.

Depression in Osteoarthritis: Current Understanding

Depression, one of the most common comorbidities with osteoarthritis (OA), affects patient prognosis and quality of life. It also increases the overall burden of disease. This subgroup of patients has not been effectively managed in clinical settings. The study aimed to direct physicians' attention to the co-occurrence of depression and OA. Therefore, this review summarizes the relevant literature published over the past 10 years. The focus is on the prevalence of and risk factors for depression in OA, the effects of depression on OA development and treatment response, comorbidity mechanisms, screening, and non-pharmacological treatment. The research on the etiology of depression has been driven largely by epidemiological studies. Recent studies have shown that high levels of pain, poor levels of function, high numbers of OA sites, and slow gait might be associated with depression. However, the pathophysiology of OA and depression comorbidities remains unclear. In addition to immune inflammation and structural changes in the brain, which have been documented in brain imaging studies, psychosocial factors may also play a role. The evidence indicates that depression can be treated with early intervention; however, adjustments may need to be made for individuals with comorbid depression in OA. It is recommended that health care providers pay more attention to depressive symptoms in patients with OA. Clinicians should develop and implement an individualized and comprehensive treatment plan for patients based on a mental health assessment and in teams with other professionals to optimize treatment outcomes.

Anxiety and Depression Impact on Inhospital Complications and Outcomes After Total Knee and Hip Arthroplasty: A Propensity Score-Weighted Retrospective Analysis

INTRODUCTION

The purpose of this study was to assess the impact of anxiety and depression on immediate inhospital outcomes and complications after total joint arthroplasty of the hip (total hip arthroplasty [THA]) and knee (total knee arthroplasty [TKA]) using a large national registry.

METHODS

Data from the National Inpatient Sample was used to identify all patients undergoing TKA and THA between 2006 and 2015. Patients were divided in four groups based on a concomitant diagnosis of depression, anxiety, depression plus anxiety, and neither depression nor anxiety (control group). Propensity score analysis was performed to determine whether these psychiatric comorbidities were risk factors for inhospital economic, disposition, and complication outcomes.

RESULTS

A total of 5,901,057 TKAs and 2,838,742 THAs were performed in our study period. The relative percentage of patients with anxiety and depression undergoing these procedures markedly increased over time. All three psychiatric comorbidity groups were markedly associated with an increased risk of postoperative anemia and were markedly associated with other inhospital complications compared with the control group. Notable associations were also found between the study groups and total charges, length of stay, and disposition.

DISCUSSION

Anxiety and depression are major risk factors for inhospital complications and are markedly associated with economic and disposition outcomes after TKA and THA. The relative proportion of patients with anxiety and depression undergoing these procedures is rapidly increasing. It is critical for clinicians to remain aware of these risk factors, and attention should be directed on the development of standardized perioperative optimization protocols and medication management for these patients.

LEVEL OF EVIDENCE

Level III, retrospective study.

Radiating pain during epidural needle insertion and catheter placement cannot be associated with postoperative persistent paresthesia: a retrospective review

Background

It has been suggested that radiating pain during spinal or epidural needle insertion and catheter placement can be an indicator of needle-related nerve injury. In this study, using a historical cohort, we investigated what factors could be associated with postoperative persistent paresthesia. In addition, we focused on radiating pain during epidural needle insertion and catheterization.

Methods

This was a retrospective review of an institutional registry containing 21,606 anesthesia cases. We conducted multivariate logistic analysis in 2736 patients, who underwent epidural anesthesia, using the incidence of postoperative persistent paresthesia as a dependent variable and other covariates, including items of the anesthesia registry and the postoperative questionnaire, as independent variables in order to investigate the factors that were significantly associated with the risk of persistent paresthesia.

Results

One hundred and seventy-six patients (6.44%) were found to have persistent paresthesia. Multivariate analysis revealed that surgical site at the extremities (odds ratio (OR), 12.5; 95% confidence interval (CI), 2.77–56.4; the reference was set at abdominal surgery), duration of general anesthesia (per 10 min) (OR, 1.02; 95% CI, 1.01–1.03), postoperative headache (OR, 1.78; 95% CI, 1.04–2.95), and days taken to visit the consultation clinic (OR, 1.03; 95% CI, 1.01–1.06) were independently associated with persistent paresthesia. Radiating pain was not significantly associated with persistent paresthesia (OR, 1.56; 95% CI, 0.69–3.54).

Conclusion

Radiating pain during epidural procedure was not statistically significantly associated with persistent paresthesia, which may imply that this radiating pain worked as a warning of nerve injury.

Correlation between pain severity and levels of anxiety and depression in osteoarthritis patients: a systematic review and meta-analysis

OBJECTIVES

Osteoarthritis (OA) is a chronic degenerative musculoskeletal disease that causes articular damage and chronic pain, with a prevalence of up to 50% in individuals >60 years of age. Patients suffering from chronic painful conditions, including OA, also frequently report anxiety or depression. A systematic review and meta-analysis were performed to assess the correlation between pain severity and depressive and anxious symptomatology in OA patients.

METHODS

A systematic search was conducted using four databases (PubMed, Medline, Scopus, and Web of Science) from inception up to 14th January of 2020. We included original articles evaluating pain severity and anxiety and/or depression severity in OA-diagnosed patients. Detailed data were extracted from each study, including patients' characteristics and pain, anxiety, and depression severity. When available, the Pearson correlation coefficient between pain and depression severity and pain and anxiety severity was collected and a meta-analysis of random effects was applied.

RESULTS

This systematic review included 121 studies, with a total of 38085 participants. The mean age was 64.3 years old and subjects were predominantly female (63%). The most used scale to evaluate pain severity was the Western Ontario and the McMaster Universities Osteoarthritis Index, while for anxiety and depression, the Hospital Anxiety and Depression Scale was the most used. The meta-analysis showed a moderate positive correlation between pain severity and both anxious (r = 0.31, p < 0.001) and depressive symptomatology (r = 0.36, p < 0.001).

CONCLUSIONS

Our results demonstrate a significant correlation between pain and depression/anxiety severity in OA patients, highlighting the need for its routine evaluation by clinicians.

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion

BACKGROUND

Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF.

METHODS

A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS.

RESULTS

Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations.

CONCLUSION

At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Men and women may be at an equivalent risk for perioperative depressive symptoms.