Aim

Predicting success of a Debridement, Antibiotics and Implant Retention (DAIR) procedure for Periprosthetic Joint Infection (PJI) remains a challenge. A failed DAIR might adversely affect the outcome of any future revision surgery for PJI. Hence, the ability to identify and optimise factors predictive of DAIR success would help target the procedure to the appropriate patient cohort and avoid unnecessary surgery for patients where a DAIR is unlikely to eradicate infection.

Abstract

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?