Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?

doi:10.1016/j.arth.2016.01.063

The Journal of Arthroplasty

Volume 31, Issue 9, Supplement, September 2016, Pages 221-226

https://doi.org/10.1016/j.arth.2016.01.063 Get rights and content

Abstract

Background

Psychiatric disease (PD) is common, and the effect on complications in total hip arthroplasty (THA) is poorly understood. The purpose of this study was to evaluate the medical and surgical postoperative complication profile in patients with PD, and we hypothesize that they will be significantly increased compared with control group.

Methods

A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease version 9 codes to identify 86,976 patients who underwent primary THA with PD including bipolar (5626), depression (82,557), and schizophrenia (3776). A cohort of 590,689 served as a control with minimum 2-year follow-up. Medical and surgical complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts.

Results

Patients with PD were more likely to be younger (age < 65 years; odds ratio [OR] = 4.51, P < .001), female (OR = 2.02, P < .001) and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, P < .001). There was a significant increase (P < .001) in 13/14 (92.8%) recorded postoperative medical complications rates at the 90-day time point. In addition, there was a statistically significant increase in periprosthetic infection (OR = 2.26, P < .001), periprosthetic fracture (OR = 2.09, P < .001), dislocation (OR = 2.30, P < .001), and THA revision (OR = 1.93, P < .001) at overall follow-up.

Conclusion

Patients with PD who undergo elective primary THA have significantly increased medical and surgical complication rates in the global period and short-term follow-up, and these patients need to be counseled accordingly.

Section snippets

Methods

A retrospective review of a 100% of the Medicare database was conducted from 2005 to 2011 using Pearl Diver Technologies (West Conshohocken, PA). This study was exempt from institutional review board approval at our institution as no protected health information was included for review. All patients who underwent primary THA with coexisting bipolar disorder, depression, or schizophrenia during the study period with minimum 2-year follow-up were included. These patients were identified using

Results

Overall, 86,976 patients were identified with a preexisting psychiatric disease including bipolar (4626), depression (82,557), and schizophrenia (3776) compared with 590,689 controls (Table 1). Patients with psychiatric disease were more likely to be younger (age < 65 years; OR = 4.51, P < .001), female (OR = 2.02, P < .001) and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, P < .001). The incidence of depression in patients undergoing THA during the

Discussion

Depression is one of the most common mental health disorders [11] and may be underappreciated as a comorbidity in total hip arthroplasty. In fact, multiple studies have reported an increasing incidence of depression in the total joint population over time 4, 12, yet data looking at the complication rate after THA in patients with PD are scarce. The 14% incidence of depression found in this study is higher than that reported in previous literature 4, 9 and may be an underestimate as the number

Conclusion

Depression and psychiatric disease are common preoperative comorbidities in patients presenting for THA. These patients are more likely to be younger, female, and more medically complex than those without PD. A multidisciplinary approach may be useful in the preoperative medical evaluation given the increased risk of medical complications in the postoperative period. Both the surgeon and the patient should be aware that with the exception of osteolysis, patients with PD had twice the odds of

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Primary aim; to determine the feasibility of implementation of the INTERMED Self-Assessment (IM-SA) in adult patients scheduled for total knee arthroplasty (TKA). Secondary aim; to measure biopsychosocial complexity, referral to psychiatry or psychology in cases of complexity and to gain insight into the relation between biopsychosocial complexity and length of stay (LOS), method of discharge (MOD) and polypharmacy.
A feasibility study was conducted with 76 participants in a general hospital in the Netherlands. Feasibility was determined by the number of completed questionnaires, time spent completing the questionnaire and the attitude of staff and patients towards the IM-SA.
A cut off point ≥19 on the IM-SA was used to determine the prevalence of biopsychosocial complexity. A case file study was performed to check if referral to psychiatry or psychology had taken place.
The Spearman's Rank Correlation Coefficient or Phi was used to determine if there was a relation between biopsychosocial complexity and LOS, MOD and polypharmacy.
All participants completed the IM-SA. The average time spent completing the questionnaire was 11.46 min (SD 5.74). The attitude towards the IM-SA was positive.
The prevalence of biopsychosocial complexity was 11.84%. Referral to psychiatry or psychology did not take place.
There was no relation between complexity and LOS (Spearman's rho (r) = 0.079, p = 0.499, MOD (Phi = 0.169, p = 0.173) and polypharmacy (Phi = 0.007, p = 0.953).
Biopsychosocial complexity can be identified in TKA patients during the pre-operative phase by using the IM-SA. Implementation of the IM-SA in a Dutch general hospital is feasible.
Association of mental health disorders with postoperative complications following total shoulder arthroplasty
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Mood disorders are highly prevalent among orthopedic patients and have been shown to be associated with adverse outcomes after orthopedic surgeries. There has been conflicting evidence regarding the relationship of mental illness with outcomes following total shoulder arthroplasty (TSA). The purpose of this study was to examine the relationship between mental health disorders and postoperative TSA outcomes in patients with anxiety, depression, bipolar disorder, and schizophrenia.
Patients with osteoarthritis undergoing a primary TSA over 2010-2021 were identified in the PearlDiver claims database. Patients with anxiety, depression, bipolar disorder, or schizophrenia, identified using the International Classification of Diseases-9 and -10 codes, were compared to a control cohort composed of patients without any of these diagnoses. Two-year surgical outcomes and 90-day medical complications were analyzed via multivariable logistic regression, controlling for age, sex, and Charlson comorbidity index.
A total of 96,039 TSA patients were identified. Four thousand eight hundred thirty-nine had an anxiety disorder, 18,936 had depression, 2100 had bipolar disorder, and 437 had schizophrenia. Average cohort age ranged between 61 and 69 years. Patients with anxiety disorders (odds ratio [OR] = 1.12), depression (OR = 1.41), bipolar disorder (OR = 1.85), and schizophrenia (OR = 1.31) were all more likely to experience an emergency department visit within 90 days when compared to the control (P < .05 for all). All groups were also more likely to have various 90-day medical complications (P < .05). Patients with depression (OR = 1.33) and bipolar disorder (OR = 1.44) were significantly more likely to undergo all-cause revision within two years postoperatively (P < .05 for all).
Mental illness is associated with worse 90-day postoperative complications after TSA, particularly emergency department visits. These complications not only increase morbidity but also resource utilization and cost of care. As TSA is an elective procedure, shoulder arthroplasty surgeons should ensure patients’ mental health is optimized with the care they need to minimize the risk of adverse postoperative complications.
Post-Traumatic Stress Disorder Is Associated With Increased Emergency Department Services and Similar Rates of Opioid Prescriptions Following Primary Total Hip Arthroplasty: A Propensity Matched Analysis
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There is a paucity of literature regarding patients who have post-traumatic stress disorder (PTSD) following primary total hip arthroplasty (THA). The purpose of this study was to compare the rates of postoperative complications, prescriptions, health care utilization, and revision arthroplasty of patients who had PTSD undergoing primary THA against a propensity matched control group of patients who did not have PTSD (NPTSD).
The TriNetX database was queried to identify PTSD patients undergoing primary THA. Patients were then propensity matched in a 1:1 ratio based on twelve preoperative characteristics to a cohort of NPTSD patients. Postoperative prescriptions and rates of health care utilization were analyzed within 5 days, 14 days, and 1 month postoperatively. Complications were analyzed within one month. Revision arthroplasty rates were analyzed within 1 year and 2 years.
A total of 198,560 patients undergoing primary THA were identified. Ultimately, 1,310 PTSD patients were successfully propensity matched to a cohort of 1,310 NPTSD patients. Patients who have PTSD presented to the emergency department at significantly higher rates than NPTSD patients within 14 days and 1 month postoperatively. Within 1 month postoperatively, cohorts were prescribed opioid analgesics at similar rates (P = .709). Patients who had PTSD received more prescriptions per patient compared to NPTSD patients. Patients who had PTSD were also found to have a higher number of total complications per person within 1 month (P = .022). Within 2 years postoperatively, rates of revision hip arthroplasty were comparable between cohorts (P = .912).
Patients who have PTSD experience similar rates of revision hip arthroplasty and opioid prescribing compared to NPTSD patients following primary THA; however, within 1 month postoperatively, emergency department visits were greater in PTSD patients. These findings can help delineate early postoperative education and expectations for patients who have PTSD in contrast to other psychiatric diagnoses.
Results of Primary Total Knee Arthroplasty in Patients on Chronic Psychotropic Medications
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Psychotropic medications are commonly used to treat several mental health conditions. The aim of this study was to determine the impact of psychotropic medications in patients undergoing primary total knee arthroplasty (TKA) with respect to postoperative opioid use, complications, patient-reported outcome measures, and satisfaction.
This is a retrospective cohort study of 514 consecutive patients undergoing primary TKA. There were 120 patients (23.3%) who were excluded due to preoperative opioid usage. The remaining 394 patients had a minimum 1-year follow-up. Of those, 133 (34%) were on psychotropic medications preoperatively and were compared to the remaining 261 (66%) patients who were not on psychotropics. Clinical data, satisfaction, Knee Society (KS) scores, Western Ontario McMaster Universities Arthritis Index, Patient-Reported Outcomes Measurement Index Score, Forgotten Joint Scores, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, postoperative opioid medication usage, and complications were compared.
The study cohort (psychotropic medications) had significantly lower postoperative KS Function, KS Knee, Forgotten Joint Scores, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario McMaster Universities Arthritis Index, and Patient-Reported Outcomes Measurement Index Score compared to the control group. The study group had a lower overall satisfaction score (Likert scale 1 to 5) and a lower percentage of patients either satisfied or very satisfied (4.55 versus 4.79, P < .001; 92.0 versus 97.24%, P = .03, respectively). Postoperative opioid usage was significantly greater in the study group at both 6.4 weeks (range, 4 to 8) and 12-month follow-up (52.76 versus 13.33%, P < .001; 5.51 versus 0.39%, P = .002, respectively). There were no differences in complications and revisions between the groups.
Patients on psychotropic medications should be educated on the risk of increased opioid consumption, diminished satisfaction, and patient-reported outcome measures following primary TKA. Given the large number of patients on psychotropic medications undergoing TKA, additional studies are needed to further improve clinical outcomes in this group.
Preoperative Veteran RAND-12 Mental Composite Score of >60 Associated With Increased Likelihood of Patient Satisfaction After Total Hip Arthroplasty
2023, Journal of Arthroplasty
The present study aimed to determine the distribution of Veterans RAND 12-Item health survey (VR-12) mental component scores (MCS) of patients undergoing primary total hip arthroplasty (THA) and the thresholds of VR-12 MCS scores that predict higher health care utilizations and 1-year patient-reported outcome measures (PROMs).
A prospective cohort of 4,194 primary THA patients (January 2016 to December 2019) were included. Multivariable and cubic spline regression models were used to test for associations between preoperative VR-12 MCS and postoperative outcomes, including: 90-day hospital resource utilization (nonhome discharge, prolonged length of stay [LOS](ie, ≥3 days), all-cause readmission), attainment of patient acceptable symptom state (PASS) at 1-year postoperative and substantial clinical benefit (SCB) in the hip disability osteoarthritis outcome score (HOOS)-pain and HOOS-physical short form.
Lower VR-12 MCS was associated with older age, obesity, Black race, women, and smokers (all P < .001). Preoperative VR-12 MCS<20 was associated with more than twice the odds of nonhome discharge (odds ratio [OR]:2.31) and prolonged LOS (OR: 3.46). VR-12 MCS >60 was associated with higher odds of achieving PASS (OR: 2.00) and SCB in HOOS-joint related (JR) (OR: 1.16). Starting VR-12 MCS ≤40, there were exponentially higher odds of worse outcomes.
Low preoperative VR-12 MCS, specifically less than 40, may predict increased health care utilization. Furthermore, preoperative VR-12 MCS>60 predicts greater satisfaction at 1 year and higher odds of achieving SCB in HOOS-JR. Quantifiable thresholds for VR-12 MCS may aid in shared decision-making and patient counseling in setting expectations or may guide specific care pathway interventions to address mental health during THA.
II.
Documented and Undocumented Psychiatric Conditions Affect the Length of Stay and Discharge Disposition Following Total Hip Arthroplasty
2022, Journal of Arthroplasty
Citation Excerpt :
This difference also affects both quality metrics and cost. In a large review of the Medicare database, Klement et al [19] demonstrated that patients with PDs were at higher risk for medical and surgical postoperative complications following THA. LOS and discharge disposition were not compared.
Despite increased efforts toward patient optimization, some patients have undocumented conditions that can affect costs and quality metrics for institutions and physicians. This study evaluates the effect of documented and undocumented psychiatric conditions on length of stay (LOS) and discharge disposition following total hip arthroplasty (THA).
A retrospective review of all primary THAs from 2015 to 2020 at a high-volume academic orthopedic specialty hospital was conducted. Patients were separated into 3 cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (−Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, and discharge disposition were assessed.
A total of 5309 patients were included; 3048 patients had no recorded psychiatric medications (control); 2261 patients took at least 1 psychiatric medication, of which 1513 (65.9%) and 748 (34.1%) patients were put in the −Dx and +Dx cohorts, respectively. American Society of Anesthesiologists class differed between groups (P < .001). The −Dx and +Dx groups had increased LOS (3.15 ± 2.37 [75.6 ± 56.9] and 3.12 ± 2.27 [74.9 ± 54.5] vs 2.42 ± 1.70 [57.6 ± 40.8] days (hours), P < .001) and were more likely to be discharged to a secondary facility (23.0% and 21.7% vs 13.8%, P < .001) than the control group. Outcomes did not significantly differ between the −Dx and +Dx cohorts.
Most THA patients’ psychiatric diagnoses were not documented. The presence of psychiatric medications was associated with longer LOS and a greater likelihood of discharge to secondary facilities. This has implications for both cost and quality metrics. Review of medications can help identify and optimize these patients before surgery.
Retrospective Cohort Study.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.01.063.

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Complications - OtherShould We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Lancet (London, England)

J Arthroplasty

J Arthroplasty

Disabil Health J

J Arthroplasty

J Arthroplasty

Lancet (London, England)

Best Pract Res Clin Rheumatol

J Arthroplasty

J Arthroplasty

J Steroid Biochem Mol Biol

J Affect Disord

J Shoulder Elbow Surg

Bone

Lancet (London, England)

J Arthroplasty

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Variables determining outcome in total hip replacement surgery

J Bone Joint Surg Br

Depressive symptoms and one year mortality among elderly patients discharged from a rehabilitation Ward after orthopaedic surgery of the lower limbs

Behav Neurol

Complications - Other
Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?