Over the last 2 decades, research into how various “preexisting conditions” affect the outcomes of orthopaedic interventions has increasingly focused on the impact of mental health (a patient’s “state of mind” and coping abilities) and psychological diagnoses such as depression. The impact of mental health, depression, and personality characteristics on patient-reported outcomes following significant skeletal trauma has been well documented in the trauma literature. In addition, previous studies in knee arthroplasty have identified depression as a major factor in suboptimal patient outcomes.
In the October 17, 2018 issue of The Journal, Halawi et al. teased out the impact of depression and mental health—independently and in combination—on patient-reported outcomes following primary total joint arthroplasty (TJA) in 469 patients at a minimum follow-up of one year.
The authors used the validated SF-12 MCS instrument to assess patient baseline mental health at the time of surgery. They also used the widely accepted WOMAC score to assess joint-specific pain, stiffness, and physical function before and after surgery. Using these tools, the authors showed that, while depression alone may diminish some patient-reported gains obtained from arthroplasty, it does not seem to affect a patient’s overall outcome as much as poor mental health prior to surgery. In this study, patients with depression but good mental health achieved patient-reported outcomes comparable to those among normal controls. Still, patients without depression and in good mental health were found to have the most robust improvements after undergoing TJA.
Orthopaedic surgeons need to better understand the interplay between these complex psychological states and patient outcomes. These authors conclude that the effect of depression on patient-reported outcomes is “less pessimistic than previously thought,” but we welcome further studies examining the link between “the mind” and orthopaedic outcomes. Finally, we should be ready to refer patients to our mental health colleagues when we detect a potential underlying nonphysical condition that might adversely affect the magnitude of benefit from the treatments we offer.
Marc Swiontkowski, MD
Ample research has revealed that a patient’s psychological status influences the outcomes of many medical interventions. While orthopaedists treating patients with multiple-system orthopaedic trauma might not think first of the patient’s mental health, they should definitely take it into account, according to a prognostic study by Weinberg et al. in the March 2, 2016 Journal of Bone & Joint Surgery.
The study found that depression was an independent predictor of increased complications among 130 polytrauma patients who had preexisting psychiatric disorders. The authors also found that, relative to patients managed by a general trauma surgery service, those managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized and were less likely to receive instructions for mental-health follow-up upon discharge. The findings prompt the authors to encourage “awareness of [psychiatric] comorbidities during the treatment of orthopaedic conditions, the involvement of mental health-care providers in care, and the arrangement for meaningful mental health follow-up at the time of discharge.”
In her commentary on the Weinberg et al. study, Margaret McQueen, MD not only concurs with the authors’ admonitions, but adds that “we should control for psychiatric distress in our outcome measures to define the effect of surgical treatment more accurately.”
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the July 15, 2015 Specialty Update on orthopaedic trauma:
–Among 46 patients with acute clavicular fractures, upright radiographs were better than supine radiographs at demonstrating clavicular displacement.
Proximal Humeral Fractures
–A prospective randomized study of 120 patients undergoing open reduction and internal fixation (ORIF) of proximal humeral fractures showed that the deltoid-split and deltopectoral approaches resulted in similar patient outcomes.
Femoral Shaft Fractures
–Multiple studies investigating femoral rotation after treatment with intramedullary rods found that, other than increasing comminution, no patient, injury, or surgical variables increased the risk for malrotation.
–Use of electromagnetic targeting for placing femoral-rod locking bolts decreased radiation exposure and may decrease surgical time when using retrograde rods.
Distal Femoral Fractures
–Proximal fixation with far cortical locking screws to dynamize bridge-plate fixation was safe and produced better healing than did standard locking implants investigated in previous studies.
Tibial Plateau Fractures
–Ten years after surgery for displaced tibial plateau fractures, 7.3% of 8426 patients needed a total knee arthroplasty, a 5.3-fold increase relative to the general population’s need for knee arthroplasty.
–Among 40 patients with surgically treated intra-articular tibial plateau fractures, the use of continuous passive motion immediately after surgery did not provide lasting range-of-motion or other clinical benefits.
Distal Tibial Fractures
–A prospective randomized trial of 142 patients found that the use of angular stable locking screws with intramedullary nailing did not improve short-term outcomes relative to the use of conventional locking screws.
–A post hoc analysis of 8- to 12-year results from a randomized trial of 56 patients demonstrated better long-term outcomes among those who were treated operatively versus nonoperatively.
–Among 31 patients randomized to undergo either ORIF or ORIF with primary subtalar fusion, researchers found no functional differences, although ORIF with primary fusion may provide quicker healing and prevents the need for late secondary fusion.
Mental Health Issues
–Among a prospective cohort of 152 patients treated operatively for one or more fractures, psychological challenges were highly prevalent, with catastrophic thinking associated with worse mid-term outcomes.
–In a prospective cohort study of 110 patients admitted with orthopaedic injuries, researchers found persistent depression to be associated with higher depression-screening scores and prior psychiatric history.
–In a prospective cohort study of 737 open fractures, injury severity—not time to surgery—was associated with deep infection.
Every clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD