SLR - February 2021 - Ryan J. Stone

The Impact of Preoperative Mental Health and Depression on Outcomes After Total Ankle Arthroplasty

Reference: Cunningham DJ, Steele JR, Allen NB, Nunley JA, Adams SB. The Impact of Preoperative Mental Health and Depression on Outcomes After Total Ankle Arthroplasty. J Bone Joint Surg Am. 2020 Dec 11.

Level of Evidence: III

Scientific Literature Review 

Reviewed By: Ryan J. Stone, DPM 
Residency Program: Grant Medical Center – Columbus, OH

Podiatric Relevance: Managing patient expectations is an integral component of reconstructive surgery. In order to optimize post-operative outcomes, the surgeon must appropriately counsel individual patients on realistic post-operative expectations. Pre-operative mental health and depression have been reported as negative predictors of patient reported outcomes in total ankle arthroplasty. Although often used interchangeably, mental health and depression are not the same. Depression is a medical condition that negatively impacts one’s individual behavior. Mental health reflects an individual’s multidimensional state of mind that is determined by physical, environmental and socioeconomic factors that impact one’s ability to cope with stressors. The authors hypothesize that patients with depression and poor baseline mental health are at risk for achieving suboptimal patient-reported outcomes following total ankle arthroplasty. 

Methods: A level III retrospective analysis of prospectively collected data in patients undergoing primary total ankle arthroplasty over a nine-year period was performed. Six hundred twelve patients were evaluated with a minimum one year follow up. Chart review was performed to identify various patient demographics and identify the diagnosis of depression. SF-36 Physical Component Summary (PCS), Mental Component Summary (MCS), Short Musculoskeletal Function Assessment (SMFA), and visual analog scale (VAS) pain scores were collected preoperatively and within one to two years of follow-up. Patients were divided into four groups based on the preoperative SF-36 MCS scores and/or pre-operative diagnosis of depression.  

Results: All cohorts demonstrated significant improvements in all outcomes. The prevalence of depression was 21.1 percent. Patients with depression and a MCS score of <35 tended to be younger females who also had high rates of smoking, and prior surgical procedures. Patients with depression and poor mental health (MCS scores <35) had worse final outcomes than patients without these risk factors. Patients with low pre-operative MCS scores and depression started and ended with the worst outcome scores and were at greatest risk for poor outcomes, compared to patients with high pre-operative MCS scores and no depression. Depression alone did not differentiate a change in outcomes, as patients with depression and good mental health scores achieved outcomes comparable to those without depression.

Conclusions: It is important to recognize that depression and mental health are not the same, and each represent different behavioral and health characteristics that ultimately influence a surgical outcome. This study provides evidence that the effect of depression on patient-reported outcomes is influenced by baseline mental health status. Patients with a pre-operative diagnosis of depression and poor mental health achieved less favorable outcomes after total ankle arthroplasty than patients in good mental health, with or without depression. Although this article does not discuss treatment of sub-optimal mental health, the findings are practical and allow the surgeon to achieve a valuable understanding of what patient populations are pre-disposed to poor outcomes following major reconstructive surgery. Pre-operative mental health screening in patients with depression should be considered in order to identify at-risk patient populations. This will ultimately aid the surgeon in establishing appropriate multi-disciplinary intervention in the peri-operative period, in order to optimize post-operative outcomes in the at-risk population undergoing major lower extremity reconstruction. 

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