Aims. The purpose of this study was to assess the prevalence of depression and anxiety symptoms in patients undergoing shoulder surgery using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety computer adaptive tests, and to determine the factors associated with more severe symptoms. Additionally, we sought to determine whether PROMIS Depression and Anxiety were associated with functional outcomes after shoulder surgery. Methods. This was a retrospective analysis of 293 patients from an urban population who underwent elective shoulder surgery from 2015 to 2018. Survey questionnaires included preoperative and two-year postoperative data. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. Results. Mean two-year PROMIS Depression and Anxiety scores significantly improved from preoperative scores, with a greater improvement observed in PROMIS Anxiety. Worse PROMIS Depression and Anxiety scores were also significantly correlated with worse PROMIS Physical Function (PF) and American Shoulder and Elbow Surgeons scores (ASES). After controlling for confounding variables, worse PROMIS Depression was an independent predictor of worse PROMIS PF, while worse PROMIS Anxiety was an independent predictor of worse PROMIS PF and ASES scores. Conclusion. Mean two-year PROMIS Depression and Anxiety scores improved after elective shoulder surgery and several patient characteristics were associated with these scores. Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes. Cite this article: Bone Joint J 2022;104-B(4):479–485

Aims. Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room. Methods. A randomized controlled trial was conducted. A total of 255 patients were included, aged five to 17 years, who needed plaster treatment for a fracture of the upper or lower limb. Randomization was stratified for age (five to 11 and 12 to 17 years). The intervention group was distracted with VR goggles and headphones during the plaster treatment, whereas the control group received standard care. As the primary outcome, the post-procedural level of anxiety was measured with the Child Fear Scale (CFS). Secondary outcomes included the children’s anxiety reduction (difference between CFS after and CFS before plaster procedure), numerical rating scale (NRS) pain, NRS satisfaction of the children and accompanying parents/guardians, and the children’s heart rates during the procedure. An independent-samples t-test and Mann-Whitney U test (depending on the data distribution) were used to analyze the data. Results. The post-procedural CFS was significantly lower (p < 0.001) in the intervention group (proportion of children with no anxiety = 78.6%) than in the control group (56.8%). The anxiety reduction, NRS pain and satisfaction scores, and heart rates showed no significant differences between the control group and the intervention group. Subanalyses showed an increased effect of VR on anxiety levels in young patients, females, upper limb fractures, and those who had had previous plaster treatment. Conclusion. VR effectively reduces the anxiety levels of children in the plaster room, especially in young girls. No statistically significant effects were seen regarding pain, heart rate, or satisfaction scores. Cite this article: Bone Joint J 2024;106-B(7):728–734

Aims. The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation. Methods. Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded. Results. Depressive and/or anxiety disorders were common before THA and TKA, with a prevalence of 30% in those who underwent primary THA, 33% in those who underwent revision THA, 32% in those who underwent primary TKA, and 35% in those who underwent revision TKA. The presence of depressive or anxiety disorders was associated with a significantly increased risk of any infection (primary THA, hazard ratio (HR) 1.5; revision THA, HR 1.9; primary TKA, HR 1.6; revision TKA, HR 1.8), revision (THA, HR 1.7; TKA, HR 1.6), re-revision (THA, HR 2.0; TKA, HR 1.6), and reoperation (primary THA, HR 1.6; revision THA, HR 2.2; primary TKA, HR 1.4; revision TKA, HR 1.9; p < 0.03 for all). Patients with preoperative depressive and/or anxiety disorders were significantly less likely to report “much better” joint function after primary THA (78% vs 87%) and primary TKA (86% vs 90%) compared with those without these disorders at two years postoperatively (p < 0.001 for all). Conclusion. The presence of depressive or anxiety disorders prior to primary or revision THA and TKA is common, and associated with a significantly higher risk of infection, revision, reoperation, and dissatisfaction. This topic deserves further study, and surgeons may consider mental health optimization to be of similar importance to preoperative variables such as diabetic control, prior to arthroplasty. Cite this article: Bone Joint J 2023;105-B(5):526–533

Aims. Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures. Patients and Methods. Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis. Results. A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R. 2. = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R. 2. = 0.4985). Age, HADSA, patient’s percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R. 2. = 0.5802). Conclusion. Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800–807

Previous studies revealed the close relation of anxiety and low back pain. Among people with chronic low back pain, anxiety is the most commonly reported mental disorder. Thus, in the literature, there are several studies considering the anxiety as a risk factor for chronic low back pain. The authors also documented a significant differences between sexes in anxiety and quality of life due to low back pain. US National Institute of Mental Health reports that the lifetime prevalence of an anxiety disorder is 60 % higher in women than in men and that the onset, severity, clinical course, and treatment response of anxiety disorders differ significantly in women. In addition, literature has showed that women may have a worse quality of life when they have low back pain. University students may undergo an undue amount of stress, with negative outcomes in terms of academic resuşts and personal, emotional or health, consequences. Moreover, stress can be experienced at different time periods, not only during university life, but also before, during the transition from undergraduate to professional level, and after, during the transition to the life work. After all these literature knowledge, we designed the study to compare the anxiety and quality of life levels of female and male specifically university students with low back pain aged between 18–26. In this study, 100 female and male university students with low back pain aged between 18–26 were included. The low back pain level were measured by Visual Analogue Scale (VAS) and the disability level due to the pain was measured by Revised Oswestry Low Back Pain Disability Questionnaire (ODI). Beck Anxiety Inventory (BAI) was used to evaluate the anxiety level and also, Short Form 36 survey (SF-36) was used to understand the quality of life for subjects. These questionnaires were asked to participants on online platform via Google Forms between March 2020 and May 2020. SPSS Version 25.0 program was used for statistical analyses. The result of the study showed that there was a statistically significant difference between female and male students on anxiety levels (p<0.05). There were no statistically differences between female and male students on ODI and VAS (p>0.05). In female group, BAI and “Physical function” and “General Health” subgroups of SF-36 have negative correlations (p<0.05). When we correlated BAI and all subgroups of SF-36 in male group, the statistical results were showed that negative correlation with all subgroups (p<0.05) except “Energy and Fatigue” subgroup (p>0.05). We conclude that female university students with low back pain have higher anxiety levels than male students. Future studies can work on young students to cope with the psychological problems for well-being

Aims. Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS. Methods. POSE was offered to 150 prospective patients over ten months (December 2018 to November 2019) Some chose to attend (Attend-POSE) and some did not attend (DNA-POSE). A third independent retrospective group of 150 patients (mean age 57.9 years (SD 14.8), 50.6% female) received surgery prior to POSE (pre-POSE). POSE consisted of an in-person 60-minute education with accompanying literature, specified using the RTSS as psychoeducative treatment components designed to optimize cognitive/affective representations of thoughts/feelings, and normalize anxieties about surgery and its aftermath. Across-group age, sex, median LOS, perioperative complications, and readmission rates were assessed using appropriate statistical tests. Results. In all, 65 (43%) patients (mean age 57.4 years (SD 18.2), 58.8% female) comprised the Attend-POSE, and 85 (57%) DNA-POSE (mean age 54.9 years (SD 15.8), 65.8% female). There were no significant between-group differences in age, sex, surgery type, complications, or readmission rates. Median LOS was statistically different across Pre-POSE (5 days ((interquartile range (IQR) 3 to 7)), Attend-POSE (3 (2 to 5)), and DNA-POSE (4 (3 to 7)), (p = 0.014). Pairwise comparisons showed statistically significant differences between Pre-POSE and Attend-POSE LOS (p = 0.011), but not between any other group comparison. In the Attend-POSE group, there was significant change toward greater surgical preparation, procedural familiarity, and less anxiety. Conclusion. POSE was associated with a significant reduction in LOS for patients undergoing spinal fusion surgery. Patients reported being better prepared for, more familiar, and less anxious about their surgery. POSE did not affect complication or readmission rates, meaning its inclusion was safe. However, uptake (43%) was disappointing and future work should explore potential barriers and challenges to attending POSE. Cite this article: Bone Jt Open 2022;3(2):135–144

Abstract. Introduction. Anxiety and depression are risk factors for poor outcome following knee replacement surgery. The aim of this study was to investigate the prevalence of anxiety and depression before and after primary (pKR) and revision knee replacement (rKR). Methodology. Retrospective cohort study. 315,720 pKR and 12,727 rKR recruited from the NHS Patient Reported Outcome Measures (PROMs) programme from 2013–2021. Anxiety and depression were defined using: (i) Survey question: “Have you been told by a doctor that you have depression? Yes/No”; (ii) EQ-5D anxiety/depression domain. Rates of EQ-5D anxiety/depression were investigated at baseline and at 6-months following surgery. The prevalence of depression was investigated by patient age and gender. Results. Overall, 28,434/315,720 (9.0%) pKR and 1,536/12,727 (12.0%) rKR reported pre-operative depression. For all age groups, depression was more common in female than male patients. Prevalence of depression reduced with age (<60 years: 16.8% pKR, 22.7% rKR; 80+ years: 5.3% pKR, 5.2% rKR). Depression was most prevalent in female patients, under 60 years undergoing rKR (25.6%). Pre-operation, 109,000/303,998 (35.9%) pKR and 5,433/12,216 rKR (44.5%) reported moderate or extreme EQ-5D anxiety/depression. Post-operation, 65,351/308,914 (21.2%) pKR and 4,176/12,409 rKR (33.7%) reported moderate or extreme EQ-5D anxiety/depression. Conclusion. Anxiety and depression were prevalent in patients undergoing knee replacement surgery. Patients undergoing revision procedures, female patients and younger patients had the highest rates of depression. Large improvements in anxiety/depression were observed at early follow-up after pKR and rKR

Introduction. Patients undergoing TJA have higher rates of anxiety and/or depression than the general population and higher costs of care. These preoperative diagnoses lead to higher levels of postoperative dissatisfaction and depression patients alone have higher readmission rates. There is significant crossover between anxiety and depressive disorders, and many patients are classed as combined. Our goal was to evaluate readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression or both. Methods. Our hospital's prospectively collected data from our statewide total joint database (MARCQI) was reviewed from 2013–2018. Rates of anxiety and/or depression were determined based preoperative anxiolytic or antidepressant medications using national drug codes. Independent sample t-tests compared continuous variables and Chi-square tests (or Fisher's exact tests) compared categorical variables. Potential risk factors were identified by multivariable logistic regression modeling. Results. 4,107 cases (1,261 THA and 2,846 TKA) were included. 176 patients (4.28%) had a readmission within the 90-day global period. 476 patients (12%) had history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (p=0.017). When patients were stratified based on THA or TKA, patients taking anxiolytic medication undergoing TKA were 120% more likely to undergo readmission within 90 days (p=0.021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (p=0.991). For THA patients neither diagnosis appeared a risk factor for readmission (p=0.852). Conclusions. Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90-days compared to patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. THA on the other hand did not appear to share this risk profile

The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between catastrophizing, anxiety, depression and postoperative pain and functional outcomes following primary TJR. A prospective cohort study of preoperative TJR patients at one academic arthroplasty centre over a one-year period was conducted. Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) at preoperative assessment. Postoperative outcomes at one-year included patient perceived level of hip/knee pain using a visual analogue scale (VAS), subjective perception of function using the Oxford Hip/Knee Scores, and objective function using the Knee Society Score (KSS) and Harris Hip scores (HHS). Median regression was used to assess pattern of relationship between preoperative PCS clinically relevant catastrophizing (CRC), abnormal HADS-A, abnormal HADS-D and postoperative outcomes at one-year. Median difference and 95% confidence interval (CI) were reported. T-tests were performed to determine mean differences in postoperative outcomes among patients with PCS CRC, abnormal HADS-A, and abnormal HADS-D scores versus those with normal scores at preoperative assessment. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). Both the PCS-rumination CRC sub-domain (median difference 1, 95% CI 0.31–1.69, p=0.005) and abnormal HADS-A (median difference 1, 95% CI 0.36–1.64, p=0.002) were identified as significant predictors of one-year VAS pain. PCS-magnification CRC sub-domain was also identified as a significant predictor of KSS/HHS at one-year (median difference 1.3, 95% CI −5.23–0.11, p=0.041). Preoperative VAS pain, Oxford and HHS/KSS scores were significantly inferior in patients who had CRC PCS, abnormal HADS-A, and abnormal HADS-D scores compared to patients with normal scores. At one-year, PCS CRC patients also had significantly inferior VAS pain (p=0.001), Oxford (p < 0 .0001) and KSS/HHS (p=0.025). Abnormal HADS-A and HADS-D patients experienced significantly inferior postoperative VAS pain (HADS-A p=0.025, HADS-D p=0.030), Oxford (HADS-A p=0.001, HADS-D p=0.030), but no difference in KSS/HHS (HADS-A = 0.069, HADS-D = 0.071) compared to patients with normal PCS/HADS scores. However, patients with CRC PCS experienced significantly greater improvement in preoperative to postoperative VAS pain (p < 0 .0001), Oxford (p=0.003) and HHS/KSS (p < 0 .0001). Similarly, patients with abnormal HADS scores showed significant improvement in preoperative to one-year postoperative change scores, as compared to normal patients in VAS pain (HADS-A p=0.011, HADS-D p=0.024), KSS/HHS (HADS-A p=0.017, HADS-D p=0.031), but not Oxford (HADS-A p=0.299, HADS-D p=0.558). Patients who are anxious, depressed or who pain catastrophize have worse preoperative function and pain. Postoperatively, pain and functional outcomes are also inferior in such patients, however they do experience a significantly greater improvement in outcomes. Furthermore, it appears that rumination and anxiety traits predict pain levels postoperatively. Although these patients report higher levels of pain postoperatively, as compared to preoperative, great improvement can be expected following hip and knee TJR

The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics. A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and Lawrence (K-L) scale. Logistic regression was used to assess pattern of relationship between preoperative characteristics and PCS or HADS. Adjusted odds ratio (OR) and 95% confidence interval (CI) were reported. A secondary quantile regression analysis examined whether a model not restricted to pre-defined PCS and HADS categories would yield comparable results to the logistic regression model described in the primary analysis. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). VAS pain (OR 1.23,95%CI 1.04–1.45) and Oxford score (OR 1.13,95%CI 1.07–1.20) were identified as significant predictors for PCS. The same two variables were the strong predictors for all sub-domains of PCS excluding rumination. Oxford Score was the only significant predictor for abnormal HADS-A (OR 1.10,95%CI 1.04–1.17) while VAS pain (OR 1.27,95%CI 1.02–1.52) and Oxford (OR 1.09,95%CI 1.01–1.17) were significant predictors for abnormal HADS-D. Similar pattern of association for PCS and HADS was observed in the quantile regression model, where larger VAS pain and Oxford scores significantly increased median PCS across all domains. Female gender, younger age or having a higher ASA grade were associated with higher median HADS-A, but unlike in the logistic regression, this association was statistically significant. Pain catastrophising and emotional disorders generally result in poor functional outcomes in TJR patients. The most important predictor of catastrophising, anxiety/depression is pain and subjective function. At risk patients include those with high preoperative pain with generally good preoperative function, as well as younger females with significant comorbidities. Such patients should be identified, and targeted psychological therapy implemented preoperatively to optimise coping strategies and adaptive behaviour to mitigate inferior TJR outcomes including pain and patient dissatisfaction

Chronic pain and psychosocial distress are generally thought to be associated in chronic musculoskeletal disorders such as non-specific neck pain. However, it is unclear whether a raised level of anxiety is necessarily a feature of longstanding, intense pain amongst patient and general population sub-groups. Post-hoc analysis. In a cohort of 70 self-selected female, non-specific neck pain sufferers, we observed relatively high levels of self-reported pain of 4.46 (measured on the 11 point numerical pain rating scale (NRS-101)) and a longstanding duration of symptoms (156 days/year). However, the mean anxiety scores observed (5.49), fell well below the clinically relevant threshold of 21 required by the Beck Anxiety Inventory. The cohort was stratified to further distinguish individuals with higher pain intensity (NRS>6) and longer symptom duration (>90 days). Although a highly statistically significant difference (p=0.000) was subsequently observed with respect to pain intensity, in the resulting sub-groups, none such a difference was noted with respect to anxiety levels. Our results indicate that chronic, intense pain and anxiety do not always appear to be related. Explanations for these findings may include that anxiety is not triggered in socially functional individuals, that individual coping strategies have come into play or in some instances that a psychological disorder like alexithymia could be a confounder. More studies are needed to clarify the specific role of anxiety in chronic non-specific musculoskeletal pain before general evidence-driven clinical extrapolations can be made

Purpose of the study and background. Although pain is usually described as a private experience, how pain is understood and responded to by others is important. A crucial feature of this process is empathy. The aim of this study was to examine the relationship between empathy for pain and observers' health anxiety and fear of pain. The role of the observer's sex and age were also examined. Methods and results. In this study 159 participants (73 males, mean age=41, SD=19.6) were presented with 16 images of individuals in pain (8 female, 8 male), and subsequently rated their empathy towards them. Participants then completed the fear of pain and health anxiety measures. Both fear of pain and health anxiety were positively associated with empathy for pain, but in the regression model only fear of pain was a significant positive predictor of empathy for pain (p< .001). Further analysis revealed that when controlling for the effects of fear of pain, the correlation between health anxiety and empathy became non-significant. The same results were found when the overall empathy for pain score was split into empathy for male and female images. Observers' sex and age were not significant predictors of empathy for pain. Conclusion. The results highlight the role of fear of pain in empathy for pain, where more fearful observers had higher levels of empathy for pain. They support current theories of empathy and the role of the underlying top-down processes in decoding another's pain. Conflict of interest: None. Sources of funding: None

Approximately one-fifth of patients are not satisfied with total knee arthroplasty (TKA). Preoperative variables associated with poorer outcomes are severity and chronicity of pain and psychological disease, which may present as anxiety and depression. It is unclear whether this is constitutional or the result of knee pain. To address this, we explored the association of anxiety and depression with knee disability before and after TKA. Forty patients undergoing TKA completed Hospital Anxiety and Depression Scale (HADS) and Oxford Knee Scores (OKS) preoperatively and at three and six months postoperatively. Both were elevated preoperatively and improved significantly post-operatively (P<0.001). The severity of preoperative anxiety and depression was associated with worse knee disability (coefficient −0.409, p=0.009). Postoperatively reduction in anxiety and depression was associated with improvement in knee disability after three (coefficient −0.459, p=0.003) and six months (coefficient −0.428, p=0.006). The difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether they are the cause or effect of pain in the knee. As anxiety and depression improves with knee pain and function, this study suggests that knee pain contributes to the psychological symptoms and that a successful TKA offers an excellent chance of improving both

Purpose and background. There is lacking evidence about the prognostic role of anxiety as prognostic in acute low back pain patients. The objective of this study was to determine whether patients with acute low back pain (ALBP) are at risk to develop chronic low back pain (CLBP) and pain-related disability after 12 weeks due to high anxiety levels. Methods and results. An observational multi-centre study was conducted in primary physiotherapy care with measurements at baseline and at 12 weeks including known prognostic factors and psychological candidate predictors for CLBP. Two hundred and four participants completed both assessments of which 51 and 54 were classified as having less than 50% decrease in pain and pain-related disability, respectively. For pain, the final model contained higher pain intensity, longer pain duration, depression symptoms, and state anxiety with explained variance 0.30, sensitivity 0.74, specificity 0.82, Likelihood Ratio 4.1 (95% CI 2.0 to 6.1) and Area Under the Curve 0.78 (95% CI 0.70 to 0.85). For pain-related disability, trait anxiety, depression symptoms, and state anxiety contributed independently to the prediction with the model's explained variance of 0.19, sensitivity 0.78, specificity 0.78, Likelihood Ratio 3.0 (95% CI 2.0 to 4.5), and Area Under the Curve 0.73 (95% CI 0.65 to 0.81). Conclusion. State anxiety in patients with ALBP is an independent predictor of CLBP at 12 weeks after baseline in primary physiotherapy care and should be measured, in addition to known prognostic factors and depression symptoms, in order to intervene and potentially decrease duration of complaints. No conflict of interest. No funding obtained

Depression and anxiety are widely prevalent amongst patients suffering from chronic diseases including osteoarthritis. National Institute for Clinical Excellence (NICE) guidelines recommend vigilance and routine screening in such chronic disease patients, and a recent King's Fund report found depression causes considerable expense to the NHS, with £1 for every £8 spent on chronic disease spent on patients mental health, costing between £8-13 billion annually. Depression increases length of hospital stay, and poorer clinical outcomes: depressed patients are 3.5 x as likely to die after suffering from myocardial infarction. Despite this, depression screening is not performed widely pre operatively. To see if there is a basis to recommend routine pre operative depression screening in hip and knee arthroplasty patients, we asked all patients attending Joint School to complete a Hospital Anxiety and Depression Scale (HADS). This is a well-validated tool for assessing the presence and degree (either mild, moderate or severe if present) of anxiety and depression, using fourteen questions, and providing a score out of 21 for each. We then correlated these results to pre operative Oxford Knee and Oxford Hip Scores to see if there was any relationship between the extent of impact of disease and any mood disorder present. 190 patients completed the questionnaire pre operatively. Of those, 82 (43%) scored as anxious. 73 (38%) scored as depressed. 47 (25%) scored as both. Overall 107 (56%) were either anxious, depressed or both. The median anxiety score was 7, with 44 (54%) scoring 8–10 (mild), 35 (43%) 11–15 (moderate) and 3 (4%) 16+ (severe). The median depression score was 6, with 53 (73%) scoring 8–10 (mild), 19 (26%) 11–15 (moderate) and 1 (1%) 16+ (severe). In order to look for an association between the severity of depression or anxiety and Oxford Scores, we grouped the Oxford Scores according to the patient's score on the HADS, and performed analysis of variance (ANOVA) to look for a significant difference between the Oxford Scores in the groups. There was no significant link between increase in Oxford Score and anxiety score (p=0.173314) but there was between Oxford Score and depression score (p=0.001377). There was equally no correlation between scores in patients classified simply as anxious or not anxious (p=0.14918) but a significant difference in Oxford Score was present between patients designated as depressed or not depressed (p=0.000297). We thus conclude depression and anxiety are very common amongst pre operative arthroplasty patients and thus assessment for this should be considered routinely preoperatively. In addition, there is a link between severity of osteoarthritis and severity of depression with increasing depression score associated with increasing Oxford Score. This makes further work to assess the reasons for this link imperative: does increasing severity of osteoarthritis result in increasing severity of depression, or does depression cause patients to feel the effects of their disease more keenly, and thus score higher on Oxford Scores? If this is the case, would patients treated for depression find the effect of their joint problems severe enough to warrant undertaking arthroplasty surgery?

Aims: Traditionally in surgery, and this is especially true in orthopaedic foot surgery, is not paid much attention to patient’s emotions, not considering how specific personality traits could affect pre and post surgical management. Following the guidelines of WHO about the treatment of pain and in order to optimize the clinical management of patients who complain of painful foot disorders such as hallux valgus, we studied the relation between level of anxiety, perception of pain and memory pain before and after the surgical procedure. Methods: In the period 2000 and 2004 we studied 88 patients who were treated with distal metatarsal osteotomy for correction of hallux valgus. In order to evaluate anxiety trait level we selected one of the most frequently employed tests in clinical medicine (S.T.A.I. Y2). To quantify the amount of pain, due to such pathology in the pre and post surgical period, FFI test (visual analogous) and a questionnaire on pain memory, were employed. Pain was studied longitudinally, in the following steps: presurgery, immediately postsurgery, daily in the first four days, and at one and two weeks interval after the procedure. The use of analgesic drugs in the first two weeks was recorded. Two years later the same patient were recalled in order to collect data related to the clinical outcome and pain memory persistence. Results: A subgroup of 33 patients showed an high anxiety trait level (score > 43), the remaining 50 patients had a score in the normal range. The statistical analysis of the data shows a direct correlation between anxiety level and pain perception in the pre surgical period. Furthermore, patients with higher level of anxiety showed an increased use of analgesic drugs in the post surgical period (the higher dosage prescribed on demand). The unpleasant memory persistence is however mitigated in the same group, possibly due to much drug assumption. Conclusions: A correct management of patients with painful diseases candidated to surgical procedures should include a comprehensive psychological evaluation in order to identify their emotional state. Especially in clinical situations requiring bilateral surgical approaches is mandatory to avoid that pain could become a traumatic experience

We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients. We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy

Study Design: To design and test a new questionnaire to assess depression and other mood states. Summary of Background Data: Measurement of depression and of other mood states in pain patients has been criticised in recent years on the grounds that most questionnaires were not developed in pain populations and suffer from criterion contamination by somatic items. In addition, there is no accepted measurement for positive emotions which are more than the absence of depression. Objective: To develop a reliable and brief tool to assess mood in pain patients. Method: Non-somatic items concerning depression, anxiety and positive outlook were extracted using exploratory factor analysis from commonly used instruments (Beck Depression Inventory and Hospital Anxiety and Depression Scale) completed by over 900 chronic pain patients. Confirmatory factor analysis was used to test the internal structure of the final item set. Items were then reworded and presented as a new questionnaire (the Depression, Anxiety and Positive Outlook Scale: DAPOS) to two new samples: patients attending pain management and patients attending osteopathy. The new questionnaire was compared with several well-known questionnaires (SF-36, BDI, PCS). The structure was calibrated and tested using confirmatory factor analysis on both samples. Finally, a sub-set of patients carried out a sorting task to test for face validity. Results and conclusion: The DAPOS performed well, indicating that it is a reliable measure of the three mood states with good initial evidence of validity in these samples

i. Measurement of depression and of other mood states in pain patients has been criticised in recent years on the grounds that most questionnaires were not developed in pain populations and suffer from criterion contamination by somatic items. In addition, there is no accepted measurement for positive emotions which are more than the absence of depression. The aim of this study was to develop a reliable and brief tool to assess mood in pain patients. ii. Nonsomatic items concerning depression, anxiety and positive outlook were extracted using exploratory factor analysis from commonly used instruments (the Beck Depression Inventory and the Hospital Anxiety and Depression Scale) completed by over 900 chronic pain patients. Confirmatory factor analysis was used to test the internal structure of the final item set. Items were then reworded and presented as a new questionnaire(the Depression, Anxiety and Positive Outlook Scale: DAPOS) to two new samples: patients attending pain management and patients attending osteopathy. The new questionnaire was compared with several well-known questionnaires (SF36, BDI, PCS). The structure was calibrated and tested using confirmatory factor analysis on both samples. Finally, a sub-set of patients carried out a sorting task to test for face validity. iii. The DAPOS performed well, indicating that it is a reliable measure of the three mood states with good initial evidence of validity in these samples

Purpose: The aim of this study was to investigate whether distress alone or in combination with personality traits associates with low back pain (LBP) in adolescence. Materials and methods: Oulu Back Study (OBS) is a sub-cohort of the Northern Finland 1986 Birth Cohort. Data was collected at 16 and 18 years. The response rate was 69% (1987/2969). Incident cases reported LBP at 18 but not at 16, whereas persistent cases reported back pain at both time points. Distress (GHQ-12) and personality traits (hostility, optimism-pessimism, trait anxiety) were inquired at 18. Logistic regression analysis, stratified for gender, with adjustment for BMI, physical activity, smoking, parents’ socioeconomic status, sedentary hours, and sleep disturbances at 16 years was used. Additionally, the psychological determinants were mutually adjusted in the final analysis. Results: Distress was associated independently with incident LBP among boys (highest quartile vs. lowest: OR 2.47; 95% CI 1.17–5.21), whereas none of the psychological determinants were significant in incident pain among girls. Trait anxiety was associated with persistent LBP among girls (OR 2.27; 1.09–4.75), and of borderline significance with boys’ persistent pain (OR 2.40; 0.99–5.84). The combination of trait anxiety and distress (highest quartiles) associated significantly with both incident and persistent pain in both genders (OR range from 1.95 to 2.36), whereas of the other combinations of distress with personality traits only pessimism associated with persistent LBP among boys (OR 2.05). Conclusions: Perceived distress and trait anxiety, alone and especially combined with each other, associate with self-reported LBP in adolescence

Purpose: The relationship between pain, quality of life (QOL) anxiety and depression in patients with chronic pain is complex. The aim of this study was focused in osteoid osteomas which treated with Radiofrequency thermal ablation (RFTA). Patients and Methods: We determine the pain characteristics severity, duration, meaning of pain, (MINESOTA score), psychological distress (HADS), physical functioning, social functioning and quality of life (SF −36) and determine which of these variables improved after Radiofrequency thermal ablation in osteoid osteomas. A total of 26 patients with osteoid osteoma which proceed in RFTA and completed the questionnaires, evaluated pain, quality of life, anxiety, depression, physical functioning, and social functioning before and after the procedure in a mean follow up of 17 months. Pearson correlation coefficients were calculated to examine the relationships among the study variables. A multiple regression analysis was performed to determine which variables were the most important predictors. Results: Pain was significantly correlated with all the other variables, in particular depression and anxiety. Pain QuoL and Depression improved dramatically after kyphoplasties in a follow up of 17 months period. Conclusion: The clinical results indicate a 100% success rate with complete remission of symptoms and no relapses having been reported at the time of those patients who have arrived at the one year follow up. CT-guided RF ablation is a safe, simple and effective method of treatment for osteoid osteoma. and improve quality of life, anxiety and depression in these patients

Aims. We performed a meta-analysis investigating the association between preoperative psychological distress and postoperative pain and function after total knee arthroplasty (TKA). Materials and Methods. Pubmed/Medline, Embase, PsycINFO, and the Cochrane library were searched for studies on the influence of preoperative psychological distress on postoperative pain and physical function after TKA. Two blinded reviewers screened for eligibility and assessed the risk of bias and the quality of evidence. We used random effects models to pool data for the meta-analysis. Results. Six prospective cohort studies, with a total of 1525 patients, were included. The random effects models showed significantly poorer outcomes in patients who preoperatively had elevated scores on the pain catastrophizing scale, worse 36-Item Short-Form Health Survey (SF-36) mental health score, symptoms of anxiety and/or depression, and somatization dysfunction. After 12 months, the standard mean difference for pain was −0.74 (95% confidence interval (CI) −1.04 to −0.44) and −0.56 (95% CI −0.80 to −0.32) for function. Conclusion. Preoperative pain catastrophizing, mental distress, symptoms of anxiety and/or depression, and somatoform disorders appear to adversely affect pain and function after TKA. Some patients undergoing TKA may therefore need psychological support to improve the outcome and quality of life

Introduction. Patient reported outcome measures (PROMs) and psychological aspects of spinal conditions play an important role in its management. Disability benefit in the social welfare system is being closely scrutinized. The PHQ9 and GAD7 are used widely in general practice to aid assessment of depression and anxiety/somatization. To date, their use in the spinal surgery out patient setting has not been assessed. Materials and Method. Over a one-year period the senior author saw 516 new patients. Each patient completed a standard spinal assessment questionnaire consisting of several demographic/aetiological questions and PROMs (VAS back, VAS leg, ODI/NDI, PHQ9 and GAD7). An analysis of these scores was performed. Results. The mean age was 54 years with 237 males and 279 females. The mean VAS Neck/Back was 6.7, VAS Limb 6, ODI/NDI 48, PHQ9 12 and GAD7 8.7. The PHQ9 and GAD7 correlated strongly with the VAS and ODI/NDI scores (r=0.3–0.4, p<0.0001). The PHQ9 correlated strongly with the GAD7 (r=0.83, p<0.0001). 163 patients (31.6%) were receiving disability benefit. Disability benefit was strongly associated with increasing age, VAS, ODI/NDI, PHQ9 and GAD7 scores (p<0.0001). Patients receiving disability benefit have more concerns regarding their pain and worse PROMs. Similar findings were found in the subgroup of 81 patients with chronic degenerative low back pain. Conclusion. The PHQ9 and GAD7 scores appear to correlate well with the standard spinal disability assessment PROMs (VAS and ODI/NDI). Patients receiving disability benefit appear to have worse PROMs including worse measures of depression and anxiety/somatization

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.

Aims

While patients with psychological distress have poorer short-term outcomes after total knee arthroplasty (TKA), their longer-term function is unknown. We aimed to 1) assess the influence of preoperative mental health status on long-term functional outcomes, quality of life, and patient satisfaction; and 2) analyze the change in mental health after TKA, in a cohort of patients with no history of mental health disorder, with a minimum of ten years’ follow-up.

Aims. The primary aim was to assess change in health-related quality of life (HRQoL) of patients as they waited from six to 12 months for a total hip (THA) or total or partial knee arthroplasty (KA). Secondary aims were to assess change in joint-specific function, mental health, quality of sleep, number living in a state worse than death (WTD), wellbeing, and patient satisfaction with their healthcare. Methods. This prospective study included 142 patients awaiting a THA (mean age 66.7 years (SD 11.4); 71 female) and 214 patients awaiting KA (mean age 69.7 years (SD 8.7); 117 female). Patients completed questionnaires (EuroQol five-dimension health questionnaire (EQ-5D), Oxford Hip and Knee Scores (OHS/OKS), Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Score (HADS), University of California, Los Angeles Activity Scale, wellbeing assessment, and satisfaction with their healthcare) at six and 12 months while awaiting surgery. Results. There was a clinical and statistically significant deterioration in the EQ-5D while awaiting THA (mean change 0.071 (95% confidence interval (CI) 0.018 to 0.124); p = 0.009) and KA (mean change 0.069 (95% CI 0.032 to 0.106); p < 0.001). For patients awaiting a THA, there were deteriorations in OHS (p = 0.003), PSQI (p = 0.008), both HADS depression (p = 0.001) and anxiety (p = 0.002), and an increased prevalence in those in a state WTD (p = 0.010). For those awaiting KA, there were significant deteriorations in OKS (p < 0.001), UCLA (p = 0.001), and HADS depression (p < 0.001) and anxiety (p < 0.001). There were significant decreases in wellbeing (satisfaction with life, feeling life to be worthwhile, and happiness) and increases in anxiety for those awaiting THA or KA (p < 0.001). Those awaiting THA (odds ratio (OR) 0.52 (95% CI 0.31 to 0.89); p = 0.016) and KA (OR 0.46 (95% CI 0.31 to 0.71); p < 0.001) had a significant decrease in satisfaction with their healthcare. Conclusion. As patients waited from six to 12 months for THA or KA, they experienced a clinically significant deterioration in HRQoL. There were also deteriorations in joint-specific function, mental health, wellbeing, and patient satisfaction with healthcare. Cite this article: Bone Joint J 2024;106-B(2):166–173

We sought to determine the relationship between patient preoperative psychological factors and postoperative THA outcomes. We performed an electronic search up to December 2021 using the following terms: “(mental OR psychological OR psychiatric) AND (function OR trait OR state OR predictor OR health) AND (outcome OR success OR recovery OR response) AND total joint arthroplasty)”. Peer-reviewed, English language studies regarding THA outcomes were analyzed for preoperative patient mental health metrics and objective postoperative results regarding pain, functionality and surgical complications. We extracted study data, assessed the risk of bias of included studies, grouped them by outcome measure and performed a GRADE assessment. Seventeen of 702 studies fulfilled inclusion criteria and were included in the review. Overall, compared to cohorts with a normal psychological status, patients with higher objective measures of preoperative depression and anxiety reported increased postoperative pain, decreased functionality and greater complications following THA. Additionally, participants with lower self-efficacy or somatization were found to have worse functional outcomes. Following surgery, both early and late pain scores remained higher in patients with preoperative depression and anxiety. Preoperative depression and anxiety may negatively impact patient reported postoperative pain, physical function and complications following THA. A meta-analysis was not performed because of the heterogeneity of studies, specifically the use of differing pain scales and measures of physical and psychological function as well as varied follow-up times. Future research could test interventions to treat pre-operative depression or anxiety and explore longitudinal outcomes in THA patients. Surgeons should consider the preoperative psychological status when counseling patients regarding expected surgical outcomes and attempt to treat a patient's depression or anxiety prior to undergoing total hip arthroplasty

Aims. Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients. Methods. This randomized controlled feasibility trial was conducted at two teaching hospitals within the South Eastern Sydney Local Health District. Adult patients (age ≥ 18 years) pending orthopaedic trauma surgery between March 2021 and September 2021 were recruited and randomized to detailed or standard methods of informed consent using a random sequence concealed in sealed, opaque envelopes. The detailed group received procedure-specific written information in addition to the standard verbal consent. The primary outcome was total recall, using a seven-point interview-administered recall questionnaire at 72 hours postoperatively. Points were awarded if the participant correctly recalled details of potential complications (maximum three points), implants used (maximum three points), and postoperative instructions (maximum one point). Secondary outcomes included the anxiety subscale of the Hospital and Anxiety Depression Scale (HADS-A) and visual analogue scale (VAS) for pain collected at 24 hours preoperatively and 72 hours postoperatively. Additionally, the Patient Satisfaction Questionnaire Short Form (PSQ-18) measured satisfaction at 72 hours postoperatively. Results. A total of 60 patients were randomized, 32 to the standard group and 28 to the detailed group. Patients in the detailed group had significantly higher total recall score compared to the standard group (mean difference 1.29 points (95% confidence interval (CI) 0.51 to 2.08); p = 0.002). There were no differences in HADS-A (mean difference 0.39 (95% CI -2.11 to 2.88); p = 0.757), VAS pain (mean difference 5.71 (95% CI -22.25 to 11.11); p = 0.499), or PSQ-18 (mean difference 0.499; 95% CI -1.6 to 3.42; p = 0.392). Conclusion. Detailed written tools are useful in improving postoperative recall in adult orthopaedic trauma patients. Cite this article: Bone Jt Open 2023;4(2):104–109

Aims. Despite new technologies for total knee arthroplasty (TKA), approximately 20% of patients are dissatisfied. A major reason for dissatisfaction and revision surgery after TKA is persistent pain. The radiological grade of osteoarthritis (OA) preoperatively has been investigated as a predictor of the outcome after TKA, with conflicting results. The aim of this study was to determine if there is a difference in the intensity of pain 12 months after TKA in relation to the preoperative radiological grade of OA alone, and the combination of the intensity of preoperative pain and radiological grade of OA. Methods. The preoperative data of 300 patients who underwent primary TKA were collected, including clinical information (age, sex, preoperative pain), psychological variables (depression, anxiety, pain catastrophizing, anticipated pain), and quantitative sensory testing (temporal summation, pressure pain thresholds, conditioned pain modulation). The preoperative radiological severity of OA was graded according to the Kellgren-Lawrence (KL) classification. Persistent pain in the knee was recorded 12 months postoperatively. Generalized linear models explored differences in postoperative pain according to the KL grade, and combined preoperative pain and KL grade. Relative risk models explored which preoperative variables were associated with the high preoperative pain/low KL grade group. Results. Pain 12 months after TKA was not associated with the preoperative KL grade alone. Significantly increased pain 12 months after TKA was found in patients with a combination of high preoperative pain and a low KL grade (p = 0.012). Patients in this group were significantly more likely to be male, younger, and have higher preoperative pain catastrophizing, higher depression, and lower anxiety (all p ≤ 0.05). Conclusion. Combined high preoperative pain and low radiological grade of OA, but not the radiological grade alone, was associated with a higher intensity of pain 12 months after primary TKA. This group may have a more complex cause of pain that requires additional psychological interventions in order to optimize the outcome of TKA. Cite this article: Bone Joint J 2022;104-B(11):1202–1208

Purpose of study and background. Psychological factors are considered to play a role in development and maintenance of chronic low back pain (CLBP). Stress or anxiety can change pain sensitivity; however, this has predominantly been studied in healthy individuals with limited work in individuals with musculoskeletal pain. The objective of this study was to quantify the effect of acute exposure to a psychosocial stressor on mechanical pain sensitivity in individuals with and without CLBP. Summary of methods and results. Six individuals with CLBP and 10 individuals without CLBP performed a 10-minute computer task under conditions of low and high psychosocial stress. Psychosocial stress was manipulated using mental maths and memory tasks combined with social evaluative threat. The effect of the stressor was evaluated using blood pressure, heart rate and the state anxiety component of the Spielberger State-Trait Anxiety Index. Mechanical pressure pain threshold (PPT) was recorded on the tibialis anterior muscle using a handheld digital pressure algometer. The stress manipulation increased self-reported anxiety (p<0.001), but not blood pressure or heart rate (p>0.06). Change in PPT from low to high stress was greater in the CLBP group (median ΔPPT = −0.5 kg/cm. 2. ) than in the control group (−0.15 kg/cm. 2. ; p=0.005). Conclusion. Individuals experienced an increase in pain sensitivity after acute exposure to a stressor designed to mimic low-level workplace stressors, and this increase was greater in individuals with CLBP than asymptomatic individuals. These results indicate that this experimental model can be used to study links between pain sensitivity and psychosocial stressors and increase our understanding of their potential role in CLBP. Conflicts of Interest: No conflicts of interest. Sources of funding: No funding obtained

Aims. This study aimed to investigate patients’ attitudes towards day-case hip and knee arthroplasty and to describe patient characteristics associated with different attitudes, with the purpose of providing an insight into the information requirements for patients that surgeons should address when informing patients about day-case surgery. Methods. A total of 5,322 patients scheduled for hip or knee arthroplasty between 2016 and 2022 were included in the study. Preoperatively, patients were asked if they were interested in day-case surgery (‘Yes’, ‘Do not know’, ‘No’). Patient demographics including age, BMI, sex, and patient-reported outcome measures (PROMs) such as the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were examined within each attitude group. Additionally, changes in attitude were assessed among patients who had completed the questionnaire in association with prior hip or knee arthroplasty. Results. Of the surveyed patients, 41.8% were interested in day-case surgery (n = 2,222), 20.8% responded ‘Do not know’ (n = 1,105), and 37.5% were not interested (n = 1,995). Patients who were not interested had a higher mean age (‘No’, 70.2 years (SD 10.0) vs ‘Yes’, 65.2 years (SD 10.7)), with a majority being female (‘No’, 71.9% female (n = 1,434) vs ‘Yes’, 48.6% female (n = 1,081)). Approximately 20% of patients responded ‘Do not know’ regardless of age, sex, and PROMs. Patients reporting anxiety/depression based on EQ-5D-3L more frequently answered ‘No’ (56.9%; 66/116) compared to those not experiencing anxiety/depression (34.9%; 1,356/3,890). Among patients who responded ‘Do not know’ before their first surgery, over 70% changed their attitude to either ‘Yes’ (29.9%; 38/127) or ‘No’ (40.9%; 52/127) at their subsequent surgery. Conclusion. From 2016 to 2022, 58.3% of hip and knee arthroplasty patients expressed uncertainty or no interest in day-case surgery. In connection with current initiatives to increase the number of day-case arthroplasty procedures, there should be a focus on informing patients to address the prevalent negative or uncertain attitude. Further research is needed to investigate what preoperative information patients consider crucial in their decision-making process regarding day-case surgery. Cite this article: Bone Joint J 2024;106-B(3 Supple A):3–9

The primary purpose of this longitudinal study was to examine the impact of physical and mental well-being on a successful return to work after cartilage or ligament knee injury. A secondary purpose was to examine the effectiveness of our program regarding ordering imaging (plain X-rays, US, MRI, CT scan), and the impact that costly investigations made in clinical management. Workers who had sustained a work-related knee injury and were assessed at the lower extremity specialty clinic of our hospital program were followed up until they were discharged. All patients completed the numeric pain rating scale (NPRS), the Lower Extremity Functional Scale (LEFS), and the Hospital Anxiety and Depression Scale (HADS) on the initial assessment and at final follow-up. We included 30 patients, mean age, 50(9), 11(37%) females, 19(63%) males. The most common mechanisms of injury were twisting (13, 45%) and falls (12, 41%). The knee injuries included 10 anterior collateral ligament (ACL), 3 posterior collateral ligament (PCL), 19 medical and lateral ligament injuries, and 22 meniscus injuries with some injuries overlapping. Ten patients (30%) underwent surgery (8 meniscectomy, two ligamentous repairs). Patients showed improvement in pain scores (p<0.0001) and the LEFS scores (p=0.004). Seventeen patients (57%) returned to full-time work and 11 (37%) were not working at the time of discharge with one patient performing part-time work, and one on re-training. Higher levels of pre (p=0.02) and post-treatment (p=0.03) depression and post-treatment anxiety (p=0.02) had a negative impact on a successful return to work. Most clients had proper investigations ordered by their family physicians in the community (24 plain x-rays, 11 US, and 21 MRI). Our team ordered only 6 plain x-rays and 6 new MRI. We found significant improvement in pain and disability in injured workers who received an expedited multidisciplinary care. Anxiety and depression were the most important predictors of poorer recovery and a less successful work status. The judicious use of costly imaging is expected to reduce the overall health care cost of an injury, while providing new important information such as adding a new diagnosis or changing the management

Aims. The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods. A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results. A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion. This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124

Aims. The adequate provision of personal protective equipment (PPE) for healthcare workers has come under considerable scrutiny during the COVID-19 pandemic. This study aimed to evaluate staff awareness of PPE guidance, perceptions of PPE measures, and concerns regarding PPE use while caring for COVID-19 patients. In addition, responses of doctors, nurses, and other healthcare professionals (OHCPs) were compared. Methods. The inclusion criteria were all staff working in clinical areas of the hospital. Staff were invited to take part using a link to an online questionnaire advertised by email, posters displayed in clinical areas, and social media. Questions grouped into the three key themes - staff awareness, perceptions, and concerns - were answered using a five-point Likert scale. The Kruskal-Wallis test was used to compare results across all three groups of staff. Results. Overall, 315 staff took part in our study. There was a high awareness of PPE guidance at 84.4%, but only 52.4% of staff reported adequate PPE provision. 67.9% were still keen to come to work, despite very high levels of anxiety relating to contracting COVID-19 despite wearing PPE. Doctors had significantly higher ratings for questions relating to PPE awareness compared to other staff groups, while nursing staff and OHCPs had significantly higher levels of anxiety compared to doctors in relation to PPE and contracting COVID-19 (p < 0.05 using a Kruskal-Wallis test). Conclusion. We believe four recommendations are key to improve PPE measures and decrease anxiety: 1) nominated ward/department PPE champions; 2) anonymized reporting for PPE concerns; 3) formal PPE education sessions; and 4) drop-in counselling sessions for staff. We hope the insight and recommendations from this study can improve the PPE situation and maintain the health and wellbeing of the clinical work force, in order to care for COVID-19 patients safely and effectively

Aims. COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms. Methods. A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory. Results. A total of 888 patients responded. Better health, pain, and mood scores were reported by upper limb patients. The longest waiters reported better health but poorer mood and anxiety scores. Overall, 82% had tried self-help measures to ease symptoms; 94% wished to proceed with their intervention; and 21% were prepared to tolerate deferral. Qualitative analysis highlighted the overall patient mood to be represented by the terms ‘understandable’, ‘frustrated’, ‘pain’, ‘disappointed’, and ‘not happy/depressed’. COVID-19-mandated health and safety measures and technology solutions were felt to be implemented well. However, patients struggled with access to doctors and pain management, quality of life (physical and psychosocial) deterioration, and delay updates. Conclusion. This is the largest study to hear the views of this ‘hidden’ cohort. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within the constraints of current resources. In response, we developed a reproducible local action plan to address highlighted issues. Cite this article: Bone Jt Open 2021;2(8):583–593

The February 2024 Trauma Roundup. 360. looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years

The June 2023 Hip & Pelvis Roundup. 360. looks at: Machine learning to identify surgical candidates for hip and knee arthroplasty: a viable option?; Poor outcome after debridement and implant retention; Can you cement polyethylene liners into well-fixed acetabular shells in hip revision?; Revision stem in primary arthroplasties: the Exeter 44/0 125 mm stem; Depression and anxiety: could they be linked to infection?; Does where you live affect your outcomes after hip and knee arthroplasties?; Racial disparities in outcomes after total hip arthroplasty and total knee arthroplasty are substantially mediated by socioeconomic disadvantage both in black and white patients

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

Aims. The aim of this study was to identify the information topics that should be addressed according to the parents of children with developmental dysplasia of the hip (DDH) in the diagnostic and treatment phase during the first year of life. Second, we explored parental recommendations to further optimize the information provision in DDH care. Methods. A qualitative study with semi-structured interviews was conducted between September and December 2020. A purposive sample of parents of children aged younger than one year, who were treated for DDH with a Pavlik harness, were interviewed until data saturation was achieved. A total of 20 interviews with 22 parents were conducted. Interviews were audio recorded, transcribed verbatim, independently reviewed, and coded into categories and themes. Results. Interviews revealed four fundamental information topics that should be addressed in the different phases of the DDH healthcare trajectory: general information (screening phase), patient-specific information (diagnostic and treatment phase), practical information (treatment phase), and future perspectives (treatment and follow-up phase). To further optimize the information provision in DDH care, parents wished for more accessible and trustworthy general information prior to the first hospital visit to be better prepared for the diagnosis. Furthermore, parents wanted more personalized and visually supported information for a better understanding of the nature of the disease and the reason for treatment. Conclusion. This study offers novel insights to optimize the information provision in DDH care. The main finding is the shift in information need from general information in the screening phase to patient-specific information in the diagnostic and treatment phase of DDH. Parents prefer visually-supported information, provided in a timely fashion, and tailored to their child’s situation. These recommendations potentially decrease parental anxiety, insecurity, confusion, and increase parental empowerment and treatment adherence throughout the diagnostic and treatment phase of DDH. Cite this article: Bone Jt Open 2023;4(7):496–506

Aims. Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO. Methods. In all, 202 consecutive patients who underwent PAO for developmental dysplasia of the hip (DDH) at our institution from 2015 to 2017 were included and followed up at 63 months (SD 10) postoperatively. Of these, 101 with complete data sets entered final analysis. Patients were assessed by questionnaire. Psychological status was measured by Brief Symptom Inventory (BSI-18), health-related quality of life was raised with 36-Item Short Form Survey (SF-36), hip functionality was measured by the short version 0f the International Hip Outcome Tool (iHOT-12), Subjective Hip Value (SHV), and Hip Disability and Outcome Score (HOS). Surgery satisfaction and pain were assessed. Dependent variables (endpoints) were postoperative quality of life (SF-36, HOS quality of life (QoL)), joint function (iHOT-12, SHV, HOS), patient satisfaction, and pain. Psychological distress was assessed by the Global Severity Index (GSI), somatization (BSI Soma), depression (BSI Depr), and anxiety (BSI Anx). Influence of psychological status was assessed by means of univariate and multiple multivariate regression analysis. Results. In multiple multivariate regression, postoperative GSI, BSI Soma, and BSI Depr had a negative effect on postoperative SF-36 (e -2.07, -3.05, and -2.67, respectively; p < 0.001), iHOT-12 (e -1.35 and -4.65, respectively; p < 0.001), SHV (e -1.20 and -2.71, respectively; p < 0.001), HOS QoL (e -2.09 and -4.79, respectively; p < 0.001), HOS Function (e -1.00 and -3.94, respectively; p < 0.001), and HOS Sport (e -1.44 and -5.29, respectively; p < 0.001), and had an effect on postoperative pain (e 0.13 and 0.37, respectively; p < 0.001). Conclusion. Psychological distress, depression, and somatization disorders affect health-related quality of life, perceived joint function, and sports ability. Pain perception is significantly increased by somatization. However, patient satisfaction with surgery is not affected. Cite this article: Bone Jt Open 2023;4(10):758–765

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

Aims. Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF. Methods. A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality. Results. A total of 70 patients with a PFF were included. EQ-5D utility scores were significantly lower on all timepoints except at six months’ follow-up compared to pre-injury. EuroQol visual analogue scale (EQ-VAS) scores at one month's follow-up were significantly lower compared to pre-injury. The percentage of reported problems at two years was higher for all dimensions except anxiety/depression when compared to pre-injury. The mean EQ-5D utility score was 0.26 higher in males compared to females (95% confidence interval (CI) 0.01 to 0.42; p = 0.003). The mean EQ-VAS score for males was 8.9 points higher when compared to females over all timepoints (95% CI 1.2 to 16.7; p = 0.027). Mortality was 10% after two years’ follow-up. Conclusion. PFF patients are a frail population with substantial functional impairment at baseline. Post-injury, they have a significant and clinically relevant lower health status two years after trauma when compared to pre-injury. Health status improves the most between one and three months after injury. Two years after PFF, more patients experience problems in mobility, self-care, usual activities, and pain/discomfort than pre-injury. Cite this article: Bone Joint J 2024;106-B(5):442–449

The primary goal of this study was to understand the subjective impact of a diagnosis of Simple Bone Cyst on children with regards to activity participation and psychosocial development. We aimed to explore the concepts of labeling, embodiment and activity participation to understand the impact of SBC. This was a qualitative study. Ten children between the ages of 4 and 17 years with SBC and their families participated in semi-structured interviews related to activity participation, social interactions and psychological impact of SBC. Interview questions were derived from psychology, sociology and philosophy literatures pertaining to illness and activity, sense of embodiment, self-concept and interactions with the social environment. Interviews were transcribed and analyzed using thematic analysis. First, children and families view SBC as an injury more than an illness and did not experience labeling or significant changes in embodiment. Second, SBCs cause anxiety in children related fear of fracture or pain, however normal function and activity participation were maintained. Third, there were significant shortcomings identified in the communication and the decision-making process between families and physicians regarding SBC management. SBC as a benign disease does not neatly fit into the category of illness or injury based on children's experiences. Children who previously perceived themselves as normal feel different and not normal following diagnosis with SBC. The experience of parents is largely one of anxiety, and much of that anxiety is derived from the uncertainty over the treatment plans for their child. The proposed framework of normality allows for the more temporary and fluid changes in perception experienced by the children in our study. The results of this study suggest that the current decision-making process in SBC is unsatisfactory leading to anxiety and worry. Parents felt pressure to make decisions regarding surgery without feeling that they sufficient information. Though understanding how children experience SBCs and how parents experience the treatment course of their child with SBC, we can shared decision-making as a potential way to reduce parents' anxiety and limit negative experience in children

Aims. Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS). Methods. UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion. The primary outcome is ‘treatment failure’ (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or ‘treatment success’ (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry. Cite this article: Bone Jt Open 2023;4(11):873–880

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. 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

Aims. The primary aim of this study was to quantify the improvement in patient-reported outcome measures (PROMs) following total hip arthroplasty (THA), as well as the extent of any deterioration through the seven-year follow-up. The secondary aim was to identify predictors of PROM improvement and deterioration. Patients and Methods. A total of 976 patients were enrolled into a prospective, international, multicentre study. Patients completed a battery of PROMs prior to THA, at three months post-THA, and at one, three, five, and seven-years post-THA. The Harris Hip Score (HHS), the 36-Item Short-Form Health Survey (SF-36) Physical Component Summary (PCS), the SF-36 Mental Component Summary (MCS), and the EuroQol five-dimension three-level (EQ-5D) index were the primary outcomes. Longitudinal changes in each PROM were investigated by piece-wise linear mixed effects models. Clinically significant deterioration was defined for each patient as a decrease of one half of a standard deviation (group baseline). Results. Improvements were noted in each PROM between the preoperative and one-year visits, with one-year values exceeding age-matched population norms. Patients with difficulty in self-care experienced less improvement in HHS (odds ratio (OR) 2.2; p = 0.003). Those with anxiety/depression experienced less improvement in PCS (OR -3.3; p = 0.002) and EQ-5D (OR -0.07; p = 0.005). Between one and seven years, obesity was associated with deterioration in HHS (1.5 points/year; p = 0.006), PCS (0.8 points/year; p < 0.001), and EQ-5D (0.02 points/year; p < 0.001). Preoperative difficulty in self-care was associated with deterioration in HHS (2.2 points/year; p < 0.001). Preoperative pain from other joints was associated with deterioration in MCS (0.8 points/year; p < 0.001). All aforementioned factors were associated with clinically significant deterioration in PROMs (p < 0.035), except anxiety/depression with regard to PCS (p = 0.060). Conclusion. The present study finds that patient factors affect the improvement and deterioration in PROMs over the medium term following THA. Special attention should be given to patients with risk factors for decreased PROMs, both preoperatively and during follow-up. Cite this article: Bone Joint J 2019;101-B:768–778

Aims. The aim of the study was to compare measures of the quality of life (QOL) after resection of a chordoma of the mobile spine with the national averages in the United States and to assess which factors influenced the QOL, symptoms of anxiety and depression, and coping with pain post-operatively in these patients. Patients and Methods. A total of 48 consecutive patients who underwent resection of a primary or recurrent chordoma of the mobile spine between 2000 and 2015 were included. A total of 34 patients completed a survey at least 12 months post-operatively. The primary outcome was the EuroQol-5 Dimensions (EQ-5D-3L) questionnaire. Secondary outcomes were the Patient-Reported Outcome Measurement Information System (PROMIS) anxiety, depression and pain interference questionnaires. Data which were recorded included the indication for surgery, the region of the tumour, the number of levels resected, the status of the surgical margins, re-operations, complications, neurological deficit, length of stay in hospital and rate of re-admission. Results. The median EQ-5D-3L score was 0.71 (interquartile range (IQR) 0.44 to 0.79) which is worse than the national average in the United States of 0.85 (p < 0.001). Anxiety (median: 55 (IQR 49 to 61), p = 0.031) and pain (median: 61 (IQR 56 to 68), p < 0.001) were also worse than the national average in the United States (50), while depression was not (median: 52 (IQR 38 to 57), p = 0.513). Patients who underwent a primary resection had better QOL and less anxiety, depression and pain compared with those who underwent resection for recurrent or residual disease. The one- and five-year probabilities were 0.96 and 0.74 for survival, 0.07 and 0.25 for tumour recurrence, and 0.02 and 0.16 for developing distant metastasis. A total of 25 local complications occurred in 20 patients (42%), and there were 50 systemic and other complications in 25 patients (52%) within 90 days. Conclusion. These patient reported outcomes and oncological and surgical outcomes can be used when counselling patients and to aid decision-making when planning surgery. Cite this article: Bone Joint J 2017;99-B:979–86

Aims. Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care. Methods. This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance. Results. Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits. Conclusion. These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity. Cite this article: Bone Jt Open 2021;2(7):493–502

Purpose and Background. Patients with low back pain are increasing globally. Physical dysfunction and psychosocial factors such as stress, anxiety, and fear of movement, often referred to as yellow flags, play a role in the persistence of low back pain. What is not known is the extent to which yellow flags are screened for and treatment adjusted accordingly by Physiotherapists in India. The aim was to determine the current knowledge and awareness of physiotherapists in India regarding psychosocial factors for managing patients with low back pain. Methods. Semi-structured interviews gathered data from of six physiotherapists, The interviews were conducted online. The data was transcribed and analysed using thematic analysis. Results. The main finding was that the physiotherapists in India had a limited knowledge regarding psychosocial factors for management of low back pain. They were not supportive of adding yellow flag screening into their routine treatments due to lack of t awareness of such screening tools Physical elements of low back pain were focused on during treatment by the therapists and recommended by management. The physiotherapists noted that high daily patient volume left them with limited time to alter treatment protocols. Conclusion. There appears to be limited information and education delivered to the physiotherapists in India regarding psychosocial factors for managing low back pain. The addition of these factors in the education and treatment protocols could address these important factors when managing patients with low back pain in India. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained