Aims. It is well described that patients with bone and joint infections (BJIs) commonly experience significant functional impairment and disability. Published literature is lacking on the impact of BJIs on mental health. Therefore, the aim of this study was to assess health-related quality of life (HRQoL) and the impact on mental health in patients with BJIs. Methods. The AO Trauma Infection Registry is a prospective multinational registry. In total, 229 adult patients with long-bone BJI were enrolled between 1 November 2012 and 31 August 2017 in 18 centres from ten countries. Clinical outcome data, demographic data, and details on infections and treatments were collected. Patient-reported outcomes using the 36-Item Short-Form Health Survey questionnaire (SF-36), Parker Mobility Score, and Katz Index of Independence in Activities of Daily Living were assessed at one, six, and 12 months. The SF-36 mental component subscales were analyzed and correlated with infection characteristics and clinical outcome. Results. The SF-36 physical component summary mean at baseline was 30.9 (95% CI 29.7 to 32.0). At one month, it was unchanged (30.5; 95% CI 29.5 to 31.5; p = 0.447); it had improved statistically significantly at six months (35.5; 95% CI 34.2 to 36.7; p < 0.001) and at 12 months (37.9; 95% CI 36.4 to 39.3; p < 0.001). The SF-36 mental component summary mean at baseline was 42.5 (95% CI 40.8 to 44.2). At one month, it was unchanged (43.1; 95% CI 41.4 to 44.8; p = 0.458); it had improved statistically significantly at six months (47.1; 95% CI 45.4 to 48.7; p < 0.001) and at 12 months (46.7; 95% CI 45.0 to 48.5; p < 0.001). All mental subscales had improved by the end of the study, but mental health status remained compromised in comparison with the average USA population. Conclusion. BJIs considerably impact HRQoL, particularly mental health. Patients suffering from BJIs reported considerable limitations in their daily and social activities due to psychological problems. Impaired mental health may be explained by the chronic nature of BJIs, and therefore the mental wellbeing of these patients should be monitored closely. Cite this article: Bone Jt Open 2024;5(9):721–728

Aims. Healthcare systems have been rapidly restructured to meet COVID-19 demand. Clinicians are working to novel clinical guidelines, treating new patient cohorts and working in unfamiliar environments. Trauma and orthopaedics (T&O) has experienced cancellation of routine clinics and operating, with redistribution of the workload and human resources. To date, no studies have evaluated the mental health impact of these changes on the T&O workforce. We report the results of a novel survey on the impact of the pandemic on the mental health of our orthopaedic workforce and the contributory factors. Methods. A 20-question survey-based cross-sectional study of orthopaedic team members was conducted during the COVID-19 pandemic. The primary objective was to identify the impact of the pandemic on mental health in the form of major depressive disorder (MDD) and general anxiety disorder (GAD). The survey incorporated the patient health questionnaire (PHQ-2), which is validated for screening of MDD, and the generalized anxiety disorder questionnaire (GAD-2), which is validated for screening of GAD. Results. There were 62 respondents (18 females and 44 males). As compared to the general population, we noted a greater estimated prevalence of GAD (17.7% vs 5.9%, p = 0.0009297) and MDD (19.4% vs 3.3%, p = 0.0000007731). The prevalence of MDD symptoms was greatest among senior house officers (SHOs) (p = 0.02216). Female respondents scored higher for symptoms of MDD (p = 0.03583) and GAD (p = 0.0001086). Those identifying as ‘Black, African, Caribbean or Black British’ displayed a higher prevalence of GAD symptoms (p = 0.001575) and felt least supported at work (p = 0.001341). Conclusion. Our study, in the first of its kind, shows a significant prevalence of GAD and MDD in the workforce. We found that SHOs, females and those of Black, African, Caribbean, or Black British origin were disproportionately affected. Action should be taken to help prevent adverse mental health outcomes for our colleagues during the pandemic. Cite this article: Bone Joint Open 2020;1-6:316–325

Aim. Musculoskeletal infection is a serious complication, however literature is lacking prospective data on its impact on mental health. The study aimed to assess mental health in patients with musculoskeletal infections and how they experience the possible mental and physical impairment. Method. All patients treated in our unit for musculoskeletal infections between July 2020 and March 2022 were prospectively included. To assess specific patient reported outcomes the following questionnaires were used: World-Health-Organization Quality-Of-Life (WHOQOL)-BREF and the Veterans-RAND-12Item Health Survey (VR-12) for mental & physical health; Patient-Health-Questionnaire (PHQ-8) for depression symptoms; Generalized-Anxiety-Disorder-Scale-7 (GAD-7) for anxiety symptoms and Somatic-Symptom-Disorder-B Criteria Scale (SSD-12) for experience of mental & physical impairment. The surveys were conducted at baseline, 6 and 12-weeks and 1-year. Results. In total 199 patients were included (31 fracture-related infections, 80 prosthetic joint infections, 40 diabetic foot syndromes and 48 other musculoskeletal infections). Physical health was significantly worse 6 weeks after treatment compared to baseline (WHOQOL p=.002; VR-12 p<.001), but significantly better at 3-months (p<.001; p=.006) and 12-months (p=.003; p<.001). Mental health was significantly worse at 3-months (WHOQOL p=.002), but at final follow-up significantly better (VR-12 p=.046). Social relationships (domain of WHOQOL) were perceived significantly worse 6 weeks and 12 months after treatment initiation (p=.003; p=.007), as were environmental factors. At baseline moderate to severe depression symptoms (PHQ-8≥10) and moderate to severe anxiety symptoms (GAD-7≥10) were observed in 14.6%, respectively 10.6% of all patients. At 12-months these were 7.4% and 3%. Over the course of treatment, only patients with DFS showed a significant change in experienced psychological or physical impairment, which was perceived significantly less compared 6 weeks to 12 months (p=.042). Conclusions. Patients with musculoskeletal infections suffer from a considerable impact on their mental health. The greatest impairment in physical health was seen 6 weeks after beginning of treatment. The psychological well-being was worse at 3-months. Environmental factors, such as mobility, activities of daily living and dependence on medication or medical treatment were worst at 3-months. Also increasingly worse social relationships over the course of treatment was observed. Further studies are needed to identify psychological impairment and related factors, as well as to determine how patients cope with their disease and treatment. This could serve as a foundation to implement treatment algorithms in order to improve patient related outcome and quality of life

Introduction. The purpose of this study was to examine the effects of baseline mental health on functional outcomes after primary knee arthroplasty by reviewing the data collected in a multi-centre prospective observational cohort study. We hypothesised that those patients with lower baseline mental health status would demonstrate significantly worse outcomes vs their counterparts with higher mental status following primary total knee arthroplasty. Methods. Data from a multi-centre prospective cohort study of PS (posterior stabilising implant) and CR (cruciate retaining implant) primary knee arthroplasty were compared to determine the relationship between baseline mental health status and functional outcomes post-surgery. Subjects were followed from the time of the index surgery to monitor outcomes and complications. Validated quality of life instruments, including SF-36, WOMAC, Knee Society Score, and an activity scale were used. Changes from baseline to 1 year on the SF-36 and WOMAC were evaluated. Regression analysis was completed to assess changes in WOMAC based on baseline SF-36 scores. All analyses were adjusted for age, BMI, gender, and implant type. Results. Baseline data was available for 436 subjects in the primary PS study and 493 subjects in the primary CR study. Patients improved significantly on all SF-36 and WOMAC components between baseline and 12 months post-surgery. Correlation and regression analysis between WOMAC and SF-36 showed that Global Health (GH), Mental Health (MH), Role-Emotional (RE), and Mental Component Score (MCS) subscales on the SF-36 were significantly associated with positive post-operative changes in WOMAC scores. Conclusion. This study examined the effects of baseline mental health on functional outcomes after primary knee arthroplasty and found that baseline mental health was a significant predictor of functional outcomes twelve months after surgery. This relationship between mental health and outcomes needs to be examined carefully to help surgeons better prepare their patients for surgery

Purpose: The purpose of this study was to examine the effects of baseline mental health on functional outcomes after primary knee arthroplasty by reviewing the data collected in a multi-center prospective observational cohort study. We hypothesized that those patients with lower baseline mental health status would demonstrate significantly worse outcomes vs. their counterparts with higher mental status following primary total knee arthroplasty. Method: Data from a multi-center prospective cohort study of PS (posterior stabilizing implant) and CR (cruciate retaining implant) primary knee arthroplasty were compared to determine the relationship between baseline mental health status and functional outcomes post-surgery. Subjects were followed from the time of the index surgery to monitor outcomes and complications. Validated quality of life instruments, including SF-36, WOMAC, Knee Society Score, and an activity scale were used. The rates of improvement from 0 to 12 months were analyzed for this study. Results: Baseline data was available for 436 subjects in the primary PS study and 493 subjects in the primary CR study. Patients improved significantly on all SF-36 and WOMAC components between baseline and 12 months post-surgery. Correlation and regression analysis between WOMAC and SF-36 showed that Global Health (GH), Mental Health (MH), and Mental Component Score (MCS) subscales on the SF-36 were significantly associated with positive post-operative changes in WOMAC scores. Conclusion: This study examined the effects of baseline mental health on functional outcomes after primary knee arthroplasty and found that baseline mental health was a significant predictor of functional outcomes twelve months after surgery. This relationship between mental health and outcomes needs to be examined carefully to help surgeons better prepare their patients for surgery

There is conflicting data from small retrospective studies as to whether pre-operative mental health influences the outcome of total knee replacement (TKR). We assessed the effect of mental disability upon the outcome of TKR and whether mental health improves post-operatively. During a three year period patients undergoing TKR for primary osteoarthritis at the study centre had prospectively outcome data recorded (n=962). Pre-operative and one year short-form (SF) 12 scores and Oxford knee scores (OKS) were obtained. The mental component of the SF-12 was stratified into four groups according to level of mental disability (none ≥50, mild 40to49, moderate 30to39, severe <30). Ethical approval was obtained (11/AL/0079). Patients with any degree of mental disability had a significantly greater subjective physical disability according to the SF-12 (p=0.06) and OKS (p<0.001). Although the improvement in the disease specific score (OKS) was not affected by a patients mental health (p=0.33). In contrast the improvement of the global physical health (SF-12) for patients with a mental disability did not improve to the same magnitude (p<0.001). However, patients with mental disability, of any degree, had a significant improvement in their mental health post-operatively (p<0.0001). Despite the similar improvement in the disease specific scores and improvement in their mental health, patients with mental disability were significantly more likely to be dissatisfied with their TKR at one year (p=0.001). TKR for patients with poor mental health benefit from improvement in their mental health and in their knee function, but do have a higher rate of dissatisfaction

Objectives: This study aims to assess the psychological profile of patients prior to total knee replacement, medial unicompartmental knee replacement and patellofemoral joint replacement and determine its effect on outcome. Methods: 113 patients were identified (41 TKR, 37 UKR and 35 PFJR). All patients had mental health assessed preoperatively using SF-12. From the 12 questions a mental and a physical summary score can be calculated (MCS and PCS). The reduced WOMAC score was used pre-operatively to assess knee function and symptoms and then recorded at 8 and 24 months post-operation to assess outcome. Results: 54% of the patients had pre-operative psychological distress. There was no statistically significant difference demonstrated between them mean MCS scores between the three operation groups. Pre-operative MCS had a significant effect such that increasing psychological distress lead to a worse twenty-four month outcome (p = 0.016). The effect of MCS is most marked in postoperative pain levels (p = 0.008) compared to function (p = 0.016). The mean 24-month rWOMAC in the severely distressed group (MCS< 40) was 28.4 compared to 17.4 in the psychologically well group (MCS> 60). Conclusions: Pre-operative mental function prior to knee arthroplasty may provide useful information to guide patients as to their expected outcome in the consent process. Those patients with a very high mental component may be counseled to that although their distress is likely to improve with surgery, their eventual outcome may be worse. The effect of MCS may however only be clinically relevant in those patients with severe mental symptoms

Aims. To identify the responsiveness, minimal clinically important difference (MCID), minimal clinical important change (MIC), and patient-acceptable symptom state (PASS) thresholds in the 36-item Short Form Health Survey questionnaire (SF-36) (v2) for each of the eight dimensions and the total score following total knee arthroplasty (TKA). Methods. There were 3,321 patients undergoing primary TKA with preoperative and one-year postoperative SF-36 scores. At one-year patients were asked how satisfied they were and “How much did the knee arthroplasty surgery improve the quality of your life?”, which was graded as: great, moderate, little (n = 277), none (n = 98), or worse. Results. Physical function, role limitations due to physical problems (‘role physical’), bodily pain, and the total score SF-36 scores demonstrated the greatest effect sizes (> 0.9). The MCID for each of SF-36 dimensions ranged from 1.7 for role emotional to 6.4 for bodily pain. The MICs for a cohort of patients ranged from -1.0 for general health to 11.1 for bodily pain. The MICs for an individual patient were marginally greater (one to two points) compared to those for a cohort, and ranging from 0.0 for general and mental health to 13.5 for physical function. The lowest PASS score threshold was associated with physical function (> 34 points) whereas the greatest threshold (> 69 points) was associated with mental health. Conclusion. The SF-36 is a responsive tool, and the estimates for MCID, MIC, and PASS thresholds that can be used to power studies, assess whether there has been a meaningful change in patients’ health-related quality of life, and can be used as a marker of achieving patient satisfaction following TKA. Cite this article: Bone Joint Res 2022;11(7):477–483

Aims. The primary aim was to assess the patient-perceived effect of restrictions imposed due to COVID-19 on rehabilitation following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Secondary aims were to assess perceived restrictions, influence on mental health, and functional outcome compared to patients undergoing surgery without restriction. Methods. During February and March 2020, 105 patients underwent THA (n = 48) or TKA (n = 57) and completed preoperative and six-month postoperative assessments. A cohort of 415 patients undergoing surgery in 2019 were used as the control. Patient demographic data, BMI, comorbidities, Oxford Hip Score (OHS) or Knee Score (OKS), and EuroQoL five-domain (EQ-5D) score were collected preoperatively and at six months postoperatively. At six months postoperatively, the 2020 patients were also asked to complete a questionnaire relating to the effect of the social restrictions on their outcome and their mental health. Results. Nearly half of the patients (47.6%, n = 50/105) felt that the restrictions imposed by COVID-19 had limited their rehabilitation and were associated with a significantly worse postoperative OKS (p < 0.001), EQ-5D score (p < 0.001), and lower satisfaction rate (p = 0.019). The reasons for the perceived limited rehabilitation were: being unable to exercise (n = 32, 64%), limited access to physiotherapy (n = 30, 60%), and no face-to-face follow-up (n = 30, 60%). A quarter (n = 26) felt that their mental health had deteriorated postoperatively; 17.1% (n = 18) felt depressed and 26.7% (n = 28) felt anxious. Joint-specific scores and satisfaction for the 2020 group were no different to the 2019 group, however patients undergoing THA in 2020 had a significantly worse postoperative EQ-5D compared to the 2019 cohort (difference 0.106; p = 0.001) which was not observed in patients undergoing TKA. Conclusion. Half of the 2020 cohort felt that their rehabilitation had been limited and was associated with worse postoperative Oxford and EQ-5D scores, and lower rates of patient satisfaction, but relative to the 2019 cohort their overall outcomes were no different, with the exception of THA patients who had a worse general health score. Level of evidence: Prospective study, Level 2. Cite this article: Bone Jt Open 2021;2(6):380–387

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than two years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008–2018 at a tertiary referral centre in New Zealand were identified. PedsQL™ questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. 40 patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0–15) and most were female (60%). Health related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% (n=27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL™ but was highlighted in qualitative feedback. We conclude that the majority of children treated for AHO reported excellent health-related quality of life up to 13 years following treatment although an negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection

There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well. A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

Pain management in spine surgery can be challenging. Cannabis might be an interesting choice for analgesia while avoiding some side effects of opioids. Recent work has reported on the potential benefits of cannabinoids for multimodal pain control, but very few studies focus on spinal surgery patients. This study aims to examine demographic and health status differences between patients who report the use of (1) cannabis, (2) narcotics, (3) cannabis and narcotics or (4) no cannabis/narcotic use. Retrospective cohort study of thoracolumbar patients enrolled in the CSORN registry after legalization of cannabis in Canada. Variables included: age, sex, modified Oswestry Disability Index (mODI), Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness leg sensation, SF-12 Quality of Life- Mental Health Component (MCS), Patient Health Questionnaire (PHQ-9), and general health state. An ANCOVA with pathology as the covariate and post-hoc analysis was run. The majority of the 704 patients enrolled (mean age: 59; female: 46.9%) were non-users (41.8%). More patients reported narcotic-use than cannabis-use (29.7% vs 12.9%) with 13.4% stating concurrent-use. MCS scores were significantly lower for patients with concurrent-use compared to no-use (mean of 39.95 vs 47.98, p=0.001) or cannabis-use (mean=45.66, p=0.043). The narcotic-use cohort had significantly worse MCS scores (mean=41.37, p=0.001) than no-use. Patients reporting no-use and cannabis-use (mean 41.39 vs 42.94) had significantly lower ODI scores than narcotic-use (mean=54.91, p=0.001) and concurrent-use (mean=50.80, p=0.001). Lower NRS-Leg pain was reported in cannabis-use (mean=5.72) compared to narcotic-use (mean=7.19) and concurrent-use (mean=7.03, p=0.001). No-use (mean=6.31) had significantly lower NRS-Leg pain than narcotic-use (p=0.011), and significantly lower NRS-back pain (mean=6.17) than narcotic-use (mean=7.16, p=0.001) and concurrent-use (mean=7.15, p=0.012). Cannabis-use reported significantly lower tingling/numbness leg scores (mean=4.85) than no-use (mean=6.14, p=0.022), narcotic-use (mean=6.67, p=0.001) and concurrent-use (mean=6.50, p=0.01). PHQ-9 scores were significantly lower for the no-use (mean=6.99) and cannabis-use (mean=8.10) than narcotic-use (mean=10.65) and concurrent-use (mean=11.93) cohorts. Narcotic-use reported a significantly lower rating of their overall health state (mean=50.03) than cannabis-use (mean=60.50, p=0.011) and no-use (mean=61.89, p=0.001). Patients with pre-operative narcotic-use or concurrent use of narcotics and cannabis experienced higher levels of disability, pain and depressive symptoms and worse mental health functioning compared to patients with no cannabis/narcotic use and cannabis only use. To the best of our knowledge, this is the first and largest study to examine the use of cannabis amongst Canadian patients with spinal pathology. This observational study lays the groundwork to better understand the potential benefits of adding cannabinoids to control pain in patients waiting for spine surgery. This will allow to refine recommendations about cannabis use for these patients

Introduction. Within the field of arthroplasty, the use of patient-reported outcome measures (PROMs) is becoming increasingly ubiquitous in an effort to employ more patient-centered methods of evaluating success. PROMs may be used to assess general health, joint-specific pain or function, or mental health. General and joint-specific questionnaires are most often used in arthroplasty research, but the relationship between arthroplasty and mental health is less well understood. Furthermore, longitudinal reports of PROM changes after arthroplasty are lacking in the literature. Our primary aim was to quantify the improvement in general, joint-specific, and mental health PROMs following total hip arthroplasty (THA) as well as the extent of any deterioration through the 7 years follow-up. Our secondary aim was to identify predictors of clinically significant PROM decline. Methods. A total of 864 patients from 17 centers across 8 countries were enrolled into a prospective study. Patients were treated with components from a single manufacturer, which have been shown to be well-functioning in other studies. Patients completed a battery of PROMs preoperatively, and at one, three, five, and seven years post-THA. Changes in PROMs between study visits were assessed via paired tests. Postoperative trends for each PROM were determined for each subject by the slope of the best-fit line of the four postoperative data points. Significant PROM deterioration was defined as one literature-defined minimum clinically important difference over 5-years. Binary logistic regressions were used to identify independent predictors of significant decline in the EuroQol (EQ-5D) visual analogue scale (VAS) for Health State, 36-Item Short Form Survey (SF-36) physical composite summary (PCS), and SF-36 mental composite summary (MCS). Results. A total of 417 completed all study visits (70% of currently eligible). All patients experienced significant improvements in all hip-specific and most general health PROMs 1-year post-THA (all p ≤ 0.002). In addition, a significant number of patients experienced a reduction in anxiety/depression following THA (p < 0.001). Hip specific PROMs remained excellent through 7-years, but most general and mental health PROs declined by the 7-year visit. A total of 133 patients (32%) experienced significant deterioration in the EQ-5D Health State. Age greater than 60 years (odds ratio (OR) = 1.9; p = 0.002) and obesity (OR = 1.7; p = 0.036) were independently predictive of EQ-5D Health State decline. A total of 58 patients (14%) experienced significant deterioration in the SF-36 PCS. Independent predictors of significant SF-36 PCS decline were lower preoperative SF-36 MCS (OR = 0.9; p = 0.002) and obesity (OR = 2.6; p = 0.009). A total of 229 patients (55%) experienced significant deterioration in the SF-36 MCS. Age greater than 60 years was predictive of significant SF-36 MCS decline (OR = 1.8; p = 0.017). Conclusion. For most patients, hip-specific PROMs will remain near the 1-year level through 7-years follow-up. Except for those with lower preoperative mental health or with obesity, gauging a patient's hip-related status at 1-year is sufficient to extrapolate their trajectory through midterm follow-up. Some patients experience mental health improvements following THA, but the majority experience a decline within 7 years of their surgery, especially older patients. Similarly, age-related decreases in general health are expected, following initial improvement 1 year after THA. Obese patients are also more likely to experience general health deterioration post-THA. By addressing the modifiable risk factors for PROM decline, the positive effects of THA may be better sustained over time

Aims. Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care. Methods. Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’. Results. The least deprived cohort were older (mean 65.95 years (SD 13.33)) than the most deprived (mean 59.48 years (SD 13.85)). Mean symptom duration was lower in the least deprived areas (68.59 months (SD 112.26)) compared to the most deprived (85.85 months (SD 122.50)). Mean pain visual analogue scores (VAS) were poorer in the most compared to the least deprived cohort (7.11 (SD 2.01) vs 5.99 (SD 2.57)), with mean mood scores also poorer (6.06 (SD 2.65) vs 4.71 (SD 2.78)). The most deprived areas exhibited lower mean quality of life (QoL) scores than the least (0.37 (SD 0.30) vs 0.53 (SD 0.31)). QoL findings correlated with health VAS and Generalized Anxiety Disorder 2-item (GAD2) scores, with the most deprived areas experiencing poorer health (health VAS 50.82 (SD 26.42) vs 57.29 (SD 24.19); GAD2: 2.94 (SD 2.35) vs 1.88 (SD 2.07)). Least-deprived patients had the highest self-reported activity levels and lowest sedentary cohort, with the converse true for patients from the most deprived areas. Conclusion. The most deprived patients experience poorer physical and mental health, with this most adversely impacted by lengthy waiting list delays. Interventions to address inequalities should focus on prioritizing the most deprived. Cite this article: Bone Jt Open 2022;3(10):777–785

Aims. Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI. Methods. A prospective longitudinal study was conducted at a level 1 trauma centre from January 2020 to December 2022. In total, 56 patients treated for FRI were enrolled. The ICD-10 symptom rating (ISR) and an expectation questionnaire were assessed at five timepoints: preoperatively, one month postoperatively, and at three, six, and 12 months. Results. Recurrent FRI cases consistently exceeded the symptom burden threshold (0.60) in ISR scores at all assessment points. The difference between preoperative-assessed total ISR scores and the 12-month follow-up was not significant in either group, with 0.04 for primary FRI (p = 0.807) and 0.01 for recurrent FRI (p = 0.768). While primary FRI patients showed decreased depression scores post surgery, recurrent FRI cases experienced an increase, reaching a peak at 12 months (1.92 vs 0.94; p < 0.001). Anxiety scores rose for both groups after surgery, notably higher in recurrent FRI cases (1.39 vs 1.02; p < 0.001). Moreover, patients with primary FRI reported lower expectations of returning to normal health at three (1.99 vs 1.11; p < 0.001) and 12 months (2.01 vs 1.33; p = 0.006). Conclusion. The findings demonstrate the significant psychological burden experienced by individuals undergoing treatment for FRI, which is more severe in recurrent FRI. Understanding the psychological dimensions of recurrent FRIs is crucial for comprehensive patient care, and underscores the importance of integrating psychological support into the treatment paradigm for such cases. Cite this article: Bone Jt Open 2024;5(7):621–627

Limb reconstruction requires high levels of patient compliance and impacts heavily on social circumstances. The epidemiology and socioeconomic description of trauma patients has been well documented, however no study has assessed the epidemiology of limb reconstruction patients. The aim of this project is to describe patients attending Limb Reconstruction Services (LRS) in order to highlight and address the social implications of their care. All LRS cases under a single surgeon in a district general hospital were included from 2010 – 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score using GeoConvert® software. Patient socioeconomic status was then ranked into national deprivation score quintiles (quintile 1 is most affluent, quintile 5 is most deprived). Deprivation scores were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was generated through AA route planner®. Patient attendance at clinic and elective or emergency admissions was also assessed. Patient outcomes were not part of this research. There were 53 patients, of which 66% (n=35) were male, with a mean age of 45 years (range 21–89 years). Most patients were smokers (55%, n=29), 83% (n=42) were ASA 1 or 2 (there were no ASA 4 patients). The majority of indications were for acute trauma (49%), chronic complications of trauma (32%), congenital deformity (15%) and salvage fusion (4%). Mental health issues affected 23% (n=12) of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort (93% vs. 76%). Deprivation quintiles identified that LRS patients were more deprived (63% in quintiles 4 and 5 vs. 12% of 1 and 2), but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles (range 0.35–105 miles, median 7 miles). The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range: 3–42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles (range 28 – 2008 miles). The total distance travelled for all 53 patients was over 26,000 miles. The results largely mirror the findings of trauma demographic and socioeconomic epidemiology, due to the majority of LRS indications being post-traumatic in this series. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of the treatment. Clinicians may want to consider a social care strategy alongside their surgical strategy and fully utilise their broader MDT to address the social inequalities in these patients. This strategy should include a mental health assessment, smoking cessation therapy, sign-posted support for employment circumstances and a plan for travel to the hospital. The utilisation and cost of ambulance services was not possible with this methodology. Further work should prospectively assess the changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment

The rate of litigation following personal injury is rising at an exponential rate with no concomitant rise in the actual incidence of these injuries. It is recognised that physical injury can lead to mental health disturbance and such mental health disturbance can delay recovery following injury. No previous study has assessed the incidence of pre-existing mental health morbidity amongst personal injury claimants. The general practitioners records of 750 consecutive personal injury claimants were examined. Mental health diagnoses prior to the index injury were noted and classified using the Diagnostic and Statistical Manual of the American Association of psychiatry. Any treatment by mental health professionals was noted. A highly significant excess of pre-injury psychiatric morbidity was identified in the study population. There was a 40% incidence of at least one mental health diagnosis. There was a highly significant excess of depression and anxiety. 10% of the study group had received treatment from at least one mental health professional. Pre-existing psychiatric morbidity appears to be an independent predictive factor for pursuing litigation following personal injury. In light of existing knowledge that such psychiatric morbidity often results in prolongation of physical symptoms and poor response to standard treatment regimes, it is important to recognise such patients when providing a prognosis in a medico-legal context

This study investigates the role of pre-operative mental health on outcome following Total Knee Replacement. Patients were recruited as part of a prospective, observational study of the outcomes of primary total knee replacement for osteothritis in centres in the United Kingdom (6 centres), United States (4 centres) and Australia (2 centres). Independent, research assistants recruited eligible patients, collecting clinical history and examination data pre-operatively, 3 and 12 month post surgery. The SF-36, WOMAC, patient satisfaction and demographic data were obtained by self-administered questionnaires. We recruited 862 eligible patients and have completed 12-month data on 742 patients (86%). Mean age was 70 years (SD 10), 59% were female, 50% were from the UK, 30% from the USA and 20% from Australia. In linear regression models, the significant correlates of preoperative mental health (in decreasing order of significance) were: low preoperative WOMAC function (Std B 8, 2; p< 0. 0001), self reported depression (Std 8 7. 6; p< 0, 0001), female gender (Std 13 2. 9 p=0, 004), older age (Std 13 2, 9; p=0. 004), other comorbid conditions (Std 3 2. 8; p=0, 005) and low income (Std B 23; p-0, 03). 12 months following surgery, low pre-operative mental health was a significance predictor of worse WOMAC pain and function (p< 0. 0001). The linear regression models adjusted for preoperative pain and function, age, sex, comorbid conditions, country and centre within country. With the exception of the pre-operative WOMAC pain and function score, low pre-operative mental health was the strongest of worse outcome 12 months after TKR. Low pre-operative mental health is a highly significant predictor of worse outcome one year after Total Knee Replacement. It may be possible to identify patients with poor mental health before surgery using the SF36 mental health score as well as self-reported depression. This may allow for effective treatment of their mental health problems prior to TKR and/or highlight the need for extra rehabilitation input to improve outcome following surgery