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Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty
The Journal of Foot & Ankle Surgery 59 (2020) 59−63
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The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty Tae Yong Kim, MD, Hyun Woo Lee, MD, Bi O Jeong, MD, PhD Orthopaedic Doctor, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
A R T I C L E
I N F O
Level of Clinical Evidence: 3 Key words: clinical result depression total ankle replacement
A B S T R A C T
Many studies have reported the relevance of depression on clinical outcomes after knee or hip arthroplasty. However, no study has investigated this relationship in total ankle arthroplasty (TAA). This study aimed to study the relationship between depressive symptoms and clinical outcomes after TAA. This retrospective comparative study investigated 40 patients who underwent TAA for end-stage ankle arthritis. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale and Patient Health Questionnaire-9. Preoperative and postoperative clinical outcomes were compared using the visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores by classifying the subjects into depressive and nondepressive groups. The mean follow-up duration was 24.3 § 7.3 (range 14 to 37) months. There were 13 and 27 subjects in the depressive and nondepressive groups, respectively. There were no significant differences in the baseline characteristics and preoperative VAS and AOFAS scores between them. The postoperative VAS score was significantly higher in the depressive group (3.1 § 2.4) than in the nondepressive group (1.4 § 2.3; p < .001). The postoperative AOFAS scores in the depressive and nondepressive groups were 89.3 § 13.4 and 95.0 § 8.1, respectively, showing a significantly superior result in the latter group (p < .001). The clinical outcomes after TAA were poorer in the patients with depressive symptoms than in those without. Depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA. Therefore, clinical considerations of these symptoms are essential before TAA. © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
Depression is known to be related to musculoskeletal pain and to have a negative relationship with orthopedic surgery outcomes (1,2). Patients with depression have been reported to experience worse pain after total joint arthroplasty of the knee, hip, and shoulder; have poor short-term and long-term clinical outcomes; and use more narcotics (3−9). Recently, depression has been reported to play a negative role on the clinical outcomes of hallux valgus corrective surgery for the ankle and foot joints (10). Total ankle arthroplasty (TAA) is performed to reduce end-stage ankle osteoarthritis pain and improve functioning (11−14). Many studies have investigated operative techniques and implants for TAA to improve the clinical outcomes, and advancements have been made (15,16). However, no study has reported on how patient-specific factors, such as depression, affect clinical outcomes after TAA. We were interested in the relevance of depression to clinical outcomes of TAA. We hypothesized that patients with depressive Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Bi O Jeong, MD, PhD, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 23 Kyunghee-daero, Dongdaemun-gu, Seoul 02447, Korea. E-mail address: [email protected] (B.O. Jeong).
symptoms experience more severe postoperative pain and have poorer clinical outcomes than those without depressive symptoms. Our primary aim was to evaluate the relationship between the clinical outcomes of TAA and depressive symptoms. We undertook a retrospective comparative study to compare the clinical outcomes of TAA in patients with depressive symptom to those without depressive symptoms. Patients and Methods Patient Selection This study retrospectively investigated patients who received TAA performed by an identical surgeon for symptomatic end-stage ankle osteoarthritis between July 2014 and July 2017. This study was approved by our institutional review board. The inclusion criteria were good bone stock, TAA performed for end-stage ankle osteoarthritis, normal vascular status, sufficient medial and lateral stabilities, and possibility for ≥12 months of follow-up. The exclusion criteria were severe coronal deformity >20° and TAA performed for rheumatoid and hemophilic arthritis. Operative Technique and Postoperative Management The cementless, unconstrained, 3-component HINTEGRA prosthesis (Newdeal SA) was used in all patients who underwent TAA. All surgeries were performed by a single surgeon (B.O.J.) while the patients were under general or spinal anesthesia and placed in the supine position. The gap between the tibialis anterior and extensor halluces longus
1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2019.07.001
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tendons was approached through a 10- to 12-cm anterior longitudinal incision. After removing the anterior synovial tissue and osteophyte, the distal part of the tibia perpendicular to the mechanical axis was resected while preserving as much subchondral bone as possible. The talus was resected parallel to the distal tibial cut. Medial, lateral, and posterior talar cutting was performed. After inserting an implant of an appropriate size, the stability, joint motion, and alignment were checked. Implant position was checked using €strom an image intensifier. If there was residual lateral ligament laxity, the modified Bro procedure or other lateral ligament-stabilizing procedures were simultaneously performed. If there was a residual hindfoot deformity, calcaneal osteotomy was concomitantly performed. Wound closure was performed after inserting the drain. Immobilization and non-weightbearing were maintained in a natural ankle position for the first 4 weeks after surgery. After 4 weeks, range-of-motion exercises were performed, and progressive weightbearing ambulation was started. The rehabilitation protocol varied depending on the additional procedures performed.
Depressive Symptom Evaluation The depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression (CES-D) Scale and Patient Health Questionnaire-9 (PHQ-9) (17,18). The CES-D Scale Korean version is a 20-item validated scale with scores ranging from 0 to 60 (19,20). The PHQ-9 Korean version is a 9-item validated scale with scores ranging from 0 to 27 (21,22). According to the literature, CES-D Scale scores of 16 and PHQ-9 scores of 10 were set as the cutoff points to classify the subjects into the depressive group and nondepressive group (23,24).
Clinical Evaluation Clinical assessments were performed preoperatively and at the final follow-up. The visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores (25,26) were measured to compare the changes in the clinical outcomes before and after surgery. Further, ranges of motion, including degrees of ankle dorsiflexion and plantarflexion, were measured, and the angle of the lateral border of the leg and foot was measured using a goniometer. We examined whether additional procedures, such as percutaneous Achilles tendon lengthening, ligament procedure, and calcaneal osteotomy, were performed. The presence of complications, including deep infection, aseptic loosening, component subsidence, periprosthetic osteolysis, technical error, iatrogenic tibialis posterior nerve injury, wound problem, heterotopic ossification, and postoperative tarsal tunnel syndrome, were analyzed.
Radiographic Evaluation Anteroposterior (AP) and lateral standing radiographs of the ankle and hindfoot alignment radiographs with weightbearing were obtained before TAA and at the final follow-up. The anterior surface angle of the distal tibia (TAS) and talar tilt of the ankle joint (TT) were measured in the AP standing radiographs of the ankle, and the lateral surface angle of the distal tibia (TLS) was measured in the lateral standing radiographs of the ankle. The heel alignment distance (HD) was measured in the hindfoot alignment radiographs with weightbearing. The TAS was defined as the angle between the tibial anatomical axis and the inner distal tibial plafond. The TT was defined as the angle between the distal tibia plafond and the upper surface of the talar dome and as the acute angle of the opening of the medial side as a positive value. The TLS was defined as the angle between the tibial anatomical axis and the line that connects the anterior-posterior boundary of the distal tibia plafond in the lateral standing radiographs of the ankle. Weightbearing hindfoot alignment radiographs were obtained using the method performed by Saltzman and el-Khoury (28). While weightbearing, the radiation was projected to be at a 20° slope from the surface toward the front from the tibialis posterior, and a film cassette was also tilted to be perpendicular to the radiation for imaging (27,28). The HD was defined as the distance between the extension of the tibial axis and the contact point of the heel (28). All digital radiographic measurements were obtained using measuring tools and a picture archiving and communication system (INFINITT Healthcare Co.). Two other orthopedic surgeons (B.O.J. and T.Y.K.) independently measured randomly selected TAS, TT, TLS, and HD twice at 1-month intervals, and the averages of the 4 measurements were used as the final measurements.
Statistical Methods Student t tests and chi-squared analyses were conducted to assess differences in patient demographics and follow-up between the groups for continuous and categorical variables, respectively. Paired t test was used to analyze the difference between 2 dependent parameters and preoperative and postoperative measurements. Student t tests were used to analyze the outcomes between the groups at baseline and the follow-up separately. Intraclass correlation coefficients were used for evaluation of interobserver and intraobserver reliabilities. All statistical analyses were performed using IBM SPSS 22.0
(IBM Corp., release 2013; IBM SPSS Statistics for Windows, version 22.0), and p values <.05 were considered statistically significant.
Results Forty-five patients were enrolled in our study. Among those, 3 patients (6.7%) were excluded owing to follow-up loss as well as 2 patients (4.4%) for whom depressive symptoms were not evaluated. The study was conducted on a final total of 40 patients (22 men and 18 women). The mean age of the patients was 61.6 § 18.2 years (range 55 to 76), and the mean follow-up duration was 24.3 § 7.3 months (range 14 to 37). The subjects with a CES-D Scale score of ≥16 and PHQ-9 score of ≥10 were classified into the depressive group; those with a CES-D Scale score <16 and PHQ-9 score <10 were classified into the nondepressive group. There were 13 subjects in the depressive group and 27 subjects in the nondepressive group. There were no significant differences in baseline characteristics, including age, sex, body mass index, complications, and follow-up duration, between the depressive and nondepressive groups (p = .629, .570, .692, .704, and .920) (Table 1). Among the patients who underwent TAA, 10 (25%) had primary osteoarthritis; 9 (22.5%) had posttraumatic osteoarthritis due to fracture; and 21 (52.5%) had posttraumatic osteoarthritis due to recurrent sprain. Simultaneously, percutaneous Achilles tendon lengthening was € strom procedure on 14 performed on 16 patients (40%), modified Bro (35%), medial displacement calcaneal osteotomy on 3 (7.5%), and subtalar arthrodesis on 3 (7.5%). Deep infection occurred in 1 patient (2.5%), medial malleolar fracture in 1 (2.5%), and insert subluxation in 1 (2.5%) (Table 2). Clinical Outcomes The preoperative and postoperative VAS and AOFAS scores of all patients significantly improved from 7.0 § 2.3 and 53.4 § 17.2 to 2.1 § 2.4 and 94.3 § 13.4, respectively (p < .001 and p < .001). The preoperative and postoperative ankle dorsiflexion and ankle plantarflexion of all patients significantly improved from 6.4° § 5.3° and 19.6° § 9.5° to Table 1 Demographic characteristics of the patients with and without depressive symptoms (N = 40 ankles in 40 patients) Characteristic Age (yr) Sex Body mass index (kg/m2) Complication Follow-up duration (mo)
Depression (n = 13)
No Depression (n = 27)
61.1 9: 4 26.3 § 3.4 1 36.9
61.6 18: 9 25.3 § 2.5 2 34.5
p Value .629 .570 .692 .704 .920
Data presented as mean § standard deviation.
Table 2 Etiology, concurrent procedures, and complications Etiology Primary osteoarthritis Posttraumatic osteoarthritis Recurrent sprain Concurrent procedure Percutaneous Achilles tendon lengthening € strom procedure Modified Bro Medial displacement calcaneal osteotomy Subtalar arthrodesis Complication Deep infection Medial malleolar fracture Insert subluxation Data presented as n (%).
10 (25%) 9 (22.5%) 21 (52.5%) 16 (40%) 14 (35%) 3 (7.5%) 3 (7.5%) 1 (2.5%) 1 (2.5%) 1 (2.5%)
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Table 3 Overall preoperative and postoperative clinical outcomes, ankle ranges of motion, and radiologic parameters (N = 40 ankles in 40 patients)
27.5° § 7.5° in the nondepressive group, respectively; p = .157 and .247) (Table 4).
Item
Preoperative
Final
p Value
Radiographic Outcomes
VAS score AOFAS score Ankle dorsiflexion (°) Ankle plantarflexion (°) TAS (°) TT (°) TLS (°) HD (mm)
7.0 § 2.3 53.4 § 17.2 6.4 § 5.3 19.6 § 9.5 88.4 § 5.4 2.4 § 5.9 78.5 § 6.6 −2.1 § 11.2
2.1 § 2.4 94.3 § 13.4 10.2 § 4.6 25.6 § 7.5 89.6 § 2.5 0.5 § 1.5 86.1 § 2.9 −1.8 § 7.9
<.001* <.001* <.001* <.001* .400 .016* <.001* .754
Data presented as mean § standard deviation. Abbreviations: AOFAS, American Orthopedic Foot and Ankle Society; HD, heel alignment distance; TAS, anterior surface angle of the distal tibia; TLS, lateral surface angle of the distal tibia; TT, talar tilt of the ankle joint; VAS, visual analog scale. * Statistically significant, p < .05.
10.2° § 4.6° and 25.6° § 7.5°, respectively (p < .001 and p < .001) (Table 3). The preoperative and postoperative VAS scores significantly improved from 6.7 § 2.2 to 3.1 § 2.4 in the depressive group and from 7.0 § 1.2 to 1.4 § 2.3 in the nondepressive group (p < .001 and p < .001). The preoperative and postoperative AOFAS scores also significantly improved from 54.4 § 14.2 to 89.3 § 13.4 in the depressive group and from 61.2 § 14.2 to 95.0 § 8.1 in the nondepressive group (p < .001 and p < .001). The preoperative and postoperative ankle dorsiflexion significantly improved from 6.2° § 4.3° to 10.7° § 3.6° in the depressive group and from 6.5° § 3.3° to 9.2° § 2.6° in the nondepressive group (p < .001 and p < .001). The preoperative and postoperative ankle plantarflexion also significantly improved from 19.5° § 4.4° to 24.7° § 6.5° in the depressive group and from 19.9° § 6.5° to 27.5° § 7.5° in the nondepressive group (p < .001 and p < .001) (Table 4). The preoperative VAS and AOFAS scores showed no significant differences (6.7 § 2.2 and 54.4 § 14.2 in the depressive group; 7.0 § 1.2 and 61.2 § 14.2 in the nondepressive group, respectively; p = .154 and .074). However, the postoperative VAS and AOFAS scores were 3.1 § 2.4 and 89.3 § 13.4 in the depressive group and 1.4 § 2.3 and 95.0 § 8.1 in the nondepressive group, respectively, with the nondepressive group showing significantly lower VAS and higher AOFAS scores (p = .031 and p < .001). The preoperative ankle dorsiflexion and plantarflexion showed no significant differences (6.2° § 4.3° and 19.5° § 4.4° in the depressive group; 6.5° § 3.3° and 19.9° § 6.5° in the nondepressive group, respectively; p = .234 and .236). The postoperative ankle dorsiflexion and plantarflexion also showed no significant differences (10.7° § 3.6° and 24.7° § 6.5° in the depressive group; 9.2° § 2.6° and
Table 4 Preoperative and postoperative clinical outcomes and ankle ranges of motion in the patients with and without depressive symptoms (N = 40 ankles in 40 patients) Item
Preoperative VAS score Preoperative AOFAS score Preoperative dorsiflexion (°) Preoperative plantarflexion (°) Final VAS score Final AOFAS score Final dorsiflexion (°) Final plantarflexion (°)
Depression (n = 13)
No Depression (n = 27)
p Value
6.7 § 2.2 54.4 § 14.2 6.2 § 4.3 19.5 § 4.4 3.1 § 2.4 89.3 § 13.4 10.7 § 3.6 24.7 § 6.5
7.0 § 1.2 61.2 § 14.2 6.5 § 3.3 19.9 § 6.5 1.4 § 2.3 95.0 § 8.1 9.2 § 2.6 27.5 § 7.5
.154 .074 .234 .236 .031* <.001* .157 .247
Data presented as mean § standard deviation. Abbreviations: AOFAS, American Orthopedic Foot and Ankle Society; VAS, visual analog scale. * Statistically significant, p < .05.
The preoperative and postoperative TAS and HD showed no significant differences in the overall patients (from 88.4° § 5.4° and −2.1 § 11.2 mm to 89.6° § 2.5° and −1.8 § 7.9 mm, respectively; p = .400 and .754). The preoperative and postoperative TT and TLS showed significant differences in the overall patients (from 2.4° § 5.9° and 78.5° § 6.6° to 0.5° § 1.5° and 86.1° § 2.9°, respectively; p = .016 and p < .001) (Table 3). The preoperative and postoperative TAS and HD showed no significant difference in the depressive group (from 87.4° § 5.3° and −2.1 § 11.3 mm to 89.7° § 2.5° and −1.7 § 7.9 mm, respectively; p = .342 and .542) and in the nondepressive group (from 87.6° § 4.3° and −3.3 § 10.3 mm to 88.9° § 1.2° and −1.3 § 6.3 mm, respectively; p = .346 and .672). Additionally, the preoperative and postoperative TT and TLS changed significantly from 2.4° § 5.8° and 78.5° § 6.5° to 0.5° § 0.7° and 86.1° § 2.9° in the depressive group (p = .021 and p < .001) and from 3.2° § 6.3° and 77.4° § 5.4° to 0.2° § 0.6° and 87.3° § 2.1° in the nondepressive group, respectively (p < .001 and p < .001) (Table 5). The preoperative TAS, TT, TLS, and HD were not significantly different between the groups (87.4° § 5.3°, 2.4° § 5.8°, 78.5° § 6.5°, and −2.1 § 11.3 mm in the depressive group; 87.6° § 4.3°, 3.2° § 6.3°, 77.4° § 5.4°, and −3.3 § 10.3 mm in the nondepressive group, respectively; p = .545, .632, .432, and .765). Additionally, the postoperative TAS, TT, TLS, and HD were not significantly different between the groups (89.7° § 2.5°, 0.5° § 0.7°, 86.1° § 2.9°, and −1.7 § 7.9 mm in the depressive group; 88.9° § 1.2°, 0.2° § 0.6°, 87.3° § 2.1°, and −1.3 § 6.3 mm in the nondepressive group, respectively; p = .841, .821, .621, and .354) (Table 5). Interobserver and Intraobserver Reliabilities Intraclass correlation coefficients with 95% confidence intervals were used to evaluate reliability. A coefficient of 1.0 designates a perfect correlation and >0.8, excellent reliability. The interobserver intraclass correlation coefficients for the TAS, TT, TLS, and HD were 0.945, 0.896, 0.967, and 0.894, respectively. The intraobserver intraclass correlation coefficients for the TAS, TT, TLS, and HD were 0.957, 0.962, 0.943, and 0.902, respectively. Discussion The most important finding of this study is that among the patients who received TAA, the patients with depressive symptoms had poorer postoperative clinical outcomes (VAS and AOFAS scores) than those Table 5 Preoperative and postoperative radiologic parameters in the patients with and without depressive symptoms (N = 40 ankles in 40 patients) Parameter
Depression (n = 13)
No Depression (n = 27)
p Value
Preoperative TAS (°) Preoperative TT (°) Preoperative TLS (°) Preoperative HD (mm) Final TAS (°) Final TT (°) Final TLS (°) Final HD (mm)
87.4 § 5.3 2.4 § 5.8 78.5 § 6.5 −2.1 § 11.3 89.7 § 2.5 0.5 § 0.7 86.1 § 2.9 −1.7 § 7.9
87.6 § 4.3 3.2 § 6.3 77.4 § 5.4 −3.3 § 10.3 88.9 § 1.2 0.2 § 0.6 87.3 § 2.1 −1.3 § 6.3
.545 .632 .432 .765 .841 .821 .621 .354
Data presented as mean § standard deviation. Abbreviations: HD, heel alignment distance; TAS, anterior surface angle of the distal tibia; TLS, lateral surface angle of the distal tibia; TT, talar tilt of the ankle joint.
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without; our hypothesis that patients with depressive symptoms will have worse pain and clinical outcomes after TAA than patients without could be supported. Psychiatric comorbidity is known to be related to medical conditions, such as coronary artery disease, diabetes, and metabolic disease (29,30). Musculoskeletal pain and depressive symptoms have an interactive relationship with each other (1,2,31,32). In particular, there have been reports that depression worsens the severity of musculoskeletal diseases and pain (1). Further, there are reportedly more depressive symptoms in patients with musculoskeletal pain than in those without musculoskeletal pain (1,33). Depression is known to have a negative response to not only the symptoms of musculoskeletal diseases, but also the treatment responses (33). The postoperative VAS score was high in patients with depression, resulting in a high usage of narcotics (33). In the area of orthopedic surgeries, it has been found that depression has a negative relationship with the long-term outcomes of lowerextremity arthroplasty, fracture, and major spine surgeries (5,34,35). These may be because depressive symptoms decreased the satisfaction with surgery and exaggerated the perception of pain and disability (36). In particular, Ellis et al (37) reported that psychopathology, including depressive symptoms, is a factor that lowers the patient-perceived outcome scores 1 year after total knee arthroplasty (TKA). In their study conducted on the outcomes of 79 cases of total hip arthroplasty (THA) for a minimum of 1 years, Riediger et al (38) reported that depression is predictive of lower scores for the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 Health inventory (SF-36). Werner et al (8) conducted a study on the outcomes of 176 cases of total shoulder arthroplasty (TSA) for a minimum of 2 years and reported that preoperative depression is an independent predictor that significantly lowers the post-TSA American Shoulder and Elbow Surgeons score. Previous studies on TKA, THA, and TSA showed that the clinical outcomes are significantly improved even in patients with depression; further, depression is a factor that affects the postoperative clinical outcomes, and evaluating patients’ depressive symptoms is essential before replacement arthroplasty. The cause of the relationship between depression and outcomes after musculoskeletal surgeries is unclear. There is an explanation that selective serotonin reuptake inhibitors or antipsychotics, which are used as treatments for depression, affect the pain pathway (3). Moreover, patients with psychologic distress have the tendency to perceive and express their pain exaggeratedly, make operative decisions at an earlier point of the disease and thus have lower satisfactions with surgery, and express symptoms after surgery actively (5). It has been confirmed that musculoskeletal pains and depressive symptoms have an interactive relationship with each other (31). Recently, the relationship between surgery and depression has been studied in the area of the ankle and foot joints (2,10). Patients with depressive symptoms had higher pain levels before hallux valgus surgery but lower pain levels after surgery than those without; however, the satisfaction regarding pain levels after surgery was very low (10). Thus, it was reported that depressive symptoms had a negative impact on the clinical and functional outcomes of hallux valgus surgery (10). In addition, in a study on psychosocial factors (mood disorder, narcotic usage, tobacco usage, diabetes, and weight) that affect pain after ankle and hindfoot reconstruction, depression and anxiety were reported to increase postoperative pain levels after orthopedic surgeries (2). In the present study, there were no differences in the pre-TAA VAS and AOFAS scores, ankle range of motion, and radiologic parameters between the patients with ankle osteoarthritis with and without depressive symptoms and in the post-TAA ankle range of motion and radiologic parameters. However, the postoperative pain level was significantly higher in the patients with depressive symptoms than in those without, whereas the AOFAS score was significantly lower. Similar to previous studies conducted on total joint arthroplasty, hallux
valgus, and ankle and hindfoot reconstruction surgeries (2), the present study showed that depressive symptoms had negative impacts on the clinical outcomes of the surgery. The study on hallux valgus by Shakked et al (10) and that on TKA by Ellis et al (37) reported that the clinical outcomes of patients with depressive symptoms were also poor; however, there was no relationship between the preoperative clinical symptoms and depressive symptoms in the present study. Accurate evaluation of depressive symptoms was possible in the present study using validated psychiatric depression diagnostic tools, including the CES-D Scale and PHQ-9. However, existing studies conducted on total joint arthroplasty, hallux valgus, and ankle and hindfoot reconstruction surgeries indirectly evaluated depressive symptoms using the Short Form-12 Mental Component Score (SF-12 MCS) based on the finding that the PHQ-9 is correlated with the SF-12 MCS (33,39). Thus, the present study, which assessed depressive symptoms using the CES-D Scale and PHQ-9, was able to measure such more accurately. Our study has the limitations that it has a relatively small sample size and a relatively short mean follow-up duration of 2 years, and that it is a retrospective study. Additional prospective studies on more cases are necessary. There is a report that musculoskeletal pain affects depressive symptoms, and such symptoms decreased after hallux valgus surgery. However, we did not examine the changes in depressive symptoms after TAA in our study; thus, another limitation is that we could not evaluate what effect TAA has on depressive symptoms. However, a single experienced surgeon performed all TAAs with technical consistency in our study. Other existing studies on the effect of depression conducted in the area of orthopedics mainly used the SF-12 MCS, and thus, accurate evaluation of depressive symptoms was difficult. Our study is significant in that it is the first study to use psychiatric diagnostic standards known to be more accurate (CES-D Scale and PHQ-9) to measure depressive symptoms and examine what effects depressive symptoms have on the clinical outcomes after TAA. Although depression was a negative factor of TAA outcomes, the clinical outcomes of the patients with depression still improved after surgery. Based on the study findings, it was confirmed that TAA is a good operative method that improves the clinical outcomes regardless of depressive symptoms. However, evaluating the depressive status of patients before surgery, which is a clinical and radiologic indication of TAA, is thought to be essential in that it provides information to predict the outcomes after surgery. In conclusion, the clinical outcomes after TAA were poor in the patients with depressive symptoms compared with those of the patients without. Because depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA, clinical considerations of such symptoms are essential before TAA.
Supplementary Materials Supplementary material associated with this article can be found in the online version at https://doi.org/10.1053/j.jfas.2019.07.001.
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Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty Tae Yong Kim, MD, Hyun Woo Lee, MD, Bi O Jeong, MD, PhD Orthopaedic Doctor, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
A R T I C L E
I N F O
Level of Clinical Evidence: 3 Key words: clinical result depression total ankle replacement
A B S T R A C T
Many studies have reported the relevance of depression on clinical outcomes after knee or hip arthroplasty. However, no study has investigated this relationship in total ankle arthroplasty (TAA). This study aimed to study the relationship between depressive symptoms and clinical outcomes after TAA. This retrospective comparative study investigated 40 patients who underwent TAA for end-stage ankle arthritis. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale and Patient Health Questionnaire-9. Preoperative and postoperative clinical outcomes were compared using the visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores by classifying the subjects into depressive and nondepressive groups. The mean follow-up duration was 24.3 § 7.3 (range 14 to 37) months. There were 13 and 27 subjects in the depressive and nondepressive groups, respectively. There were no significant differences in the baseline characteristics and preoperative VAS and AOFAS scores between them. The postoperative VAS score was significantly higher in the depressive group (3.1 § 2.4) than in the nondepressive group (1.4 § 2.3; p < .001). The postoperative AOFAS scores in the depressive and nondepressive groups were 89.3 § 13.4 and 95.0 § 8.1, respectively, showing a significantly superior result in the latter group (p < .001). The clinical outcomes after TAA were poorer in the patients with depressive symptoms than in those without. Depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA. Therefore, clinical considerations of these symptoms are essential before TAA. © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
Depression is known to be related to musculoskeletal pain and to have a negative relationship with orthopedic surgery outcomes (1,2). Patients with depression have been reported to experience worse pain after total joint arthroplasty of the knee, hip, and shoulder; have poor short-term and long-term clinical outcomes; and use more narcotics (3−9). Recently, depression has been reported to play a negative role on the clinical outcomes of hallux valgus corrective surgery for the ankle and foot joints (10). Total ankle arthroplasty (TAA) is performed to reduce end-stage ankle osteoarthritis pain and improve functioning (11−14). Many studies have investigated operative techniques and implants for TAA to improve the clinical outcomes, and advancements have been made (15,16). However, no study has reported on how patient-specific factors, such as depression, affect clinical outcomes after TAA. We were interested in the relevance of depression to clinical outcomes of TAA. We hypothesized that patients with depressive Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Bi O Jeong, MD, PhD, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 23 Kyunghee-daero, Dongdaemun-gu, Seoul 02447, Korea. E-mail address: [email protected] (B.O. Jeong).
symptoms experience more severe postoperative pain and have poorer clinical outcomes than those without depressive symptoms. Our primary aim was to evaluate the relationship between the clinical outcomes of TAA and depressive symptoms. We undertook a retrospective comparative study to compare the clinical outcomes of TAA in patients with depressive symptom to those without depressive symptoms. Patients and Methods Patient Selection This study retrospectively investigated patients who received TAA performed by an identical surgeon for symptomatic end-stage ankle osteoarthritis between July 2014 and July 2017. This study was approved by our institutional review board. The inclusion criteria were good bone stock, TAA performed for end-stage ankle osteoarthritis, normal vascular status, sufficient medial and lateral stabilities, and possibility for ≥12 months of follow-up. The exclusion criteria were severe coronal deformity >20° and TAA performed for rheumatoid and hemophilic arthritis. Operative Technique and Postoperative Management The cementless, unconstrained, 3-component HINTEGRA prosthesis (Newdeal SA) was used in all patients who underwent TAA. All surgeries were performed by a single surgeon (B.O.J.) while the patients were under general or spinal anesthesia and placed in the supine position. The gap between the tibialis anterior and extensor halluces longus
1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2019.07.001
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tendons was approached through a 10- to 12-cm anterior longitudinal incision. After removing the anterior synovial tissue and osteophyte, the distal part of the tibia perpendicular to the mechanical axis was resected while preserving as much subchondral bone as possible. The talus was resected parallel to the distal tibial cut. Medial, lateral, and posterior talar cutting was performed. After inserting an implant of an appropriate size, the stability, joint motion, and alignment were checked. Implant position was checked using €strom an image intensifier. If there was residual lateral ligament laxity, the modified Bro procedure or other lateral ligament-stabilizing procedures were simultaneously performed. If there was a residual hindfoot deformity, calcaneal osteotomy was concomitantly performed. Wound closure was performed after inserting the drain. Immobilization and non-weightbearing were maintained in a natural ankle position for the first 4 weeks after surgery. After 4 weeks, range-of-motion exercises were performed, and progressive weightbearing ambulation was started. The rehabilitation protocol varied depending on the additional procedures performed.
Depressive Symptom Evaluation The depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression (CES-D) Scale and Patient Health Questionnaire-9 (PHQ-9) (17,18). The CES-D Scale Korean version is a 20-item validated scale with scores ranging from 0 to 60 (19,20). The PHQ-9 Korean version is a 9-item validated scale with scores ranging from 0 to 27 (21,22). According to the literature, CES-D Scale scores of 16 and PHQ-9 scores of 10 were set as the cutoff points to classify the subjects into the depressive group and nondepressive group (23,24).
Clinical Evaluation Clinical assessments were performed preoperatively and at the final follow-up. The visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores (25,26) were measured to compare the changes in the clinical outcomes before and after surgery. Further, ranges of motion, including degrees of ankle dorsiflexion and plantarflexion, were measured, and the angle of the lateral border of the leg and foot was measured using a goniometer. We examined whether additional procedures, such as percutaneous Achilles tendon lengthening, ligament procedure, and calcaneal osteotomy, were performed. The presence of complications, including deep infection, aseptic loosening, component subsidence, periprosthetic osteolysis, technical error, iatrogenic tibialis posterior nerve injury, wound problem, heterotopic ossification, and postoperative tarsal tunnel syndrome, were analyzed.
Radiographic Evaluation Anteroposterior (AP) and lateral standing radiographs of the ankle and hindfoot alignment radiographs with weightbearing were obtained before TAA and at the final follow-up. The anterior surface angle of the distal tibia (TAS) and talar tilt of the ankle joint (TT) were measured in the AP standing radiographs of the ankle, and the lateral surface angle of the distal tibia (TLS) was measured in the lateral standing radiographs of the ankle. The heel alignment distance (HD) was measured in the hindfoot alignment radiographs with weightbearing. The TAS was defined as the angle between the tibial anatomical axis and the inner distal tibial plafond. The TT was defined as the angle between the distal tibia plafond and the upper surface of the talar dome and as the acute angle of the opening of the medial side as a positive value. The TLS was defined as the angle between the tibial anatomical axis and the line that connects the anterior-posterior boundary of the distal tibia plafond in the lateral standing radiographs of the ankle. Weightbearing hindfoot alignment radiographs were obtained using the method performed by Saltzman and el-Khoury (28). While weightbearing, the radiation was projected to be at a 20° slope from the surface toward the front from the tibialis posterior, and a film cassette was also tilted to be perpendicular to the radiation for imaging (27,28). The HD was defined as the distance between the extension of the tibial axis and the contact point of the heel (28). All digital radiographic measurements were obtained using measuring tools and a picture archiving and communication system (INFINITT Healthcare Co.). Two other orthopedic surgeons (B.O.J. and T.Y.K.) independently measured randomly selected TAS, TT, TLS, and HD twice at 1-month intervals, and the averages of the 4 measurements were used as the final measurements.
Statistical Methods Student t tests and chi-squared analyses were conducted to assess differences in patient demographics and follow-up between the groups for continuous and categorical variables, respectively. Paired t test was used to analyze the difference between 2 dependent parameters and preoperative and postoperative measurements. Student t tests were used to analyze the outcomes between the groups at baseline and the follow-up separately. Intraclass correlation coefficients were used for evaluation of interobserver and intraobserver reliabilities. All statistical analyses were performed using IBM SPSS 22.0
(IBM Corp., release 2013; IBM SPSS Statistics for Windows, version 22.0), and p values <.05 were considered statistically significant.
Results Forty-five patients were enrolled in our study. Among those, 3 patients (6.7%) were excluded owing to follow-up loss as well as 2 patients (4.4%) for whom depressive symptoms were not evaluated. The study was conducted on a final total of 40 patients (22 men and 18 women). The mean age of the patients was 61.6 § 18.2 years (range 55 to 76), and the mean follow-up duration was 24.3 § 7.3 months (range 14 to 37). The subjects with a CES-D Scale score of ≥16 and PHQ-9 score of ≥10 were classified into the depressive group; those with a CES-D Scale score <16 and PHQ-9 score <10 were classified into the nondepressive group. There were 13 subjects in the depressive group and 27 subjects in the nondepressive group. There were no significant differences in baseline characteristics, including age, sex, body mass index, complications, and follow-up duration, between the depressive and nondepressive groups (p = .629, .570, .692, .704, and .920) (Table 1). Among the patients who underwent TAA, 10 (25%) had primary osteoarthritis; 9 (22.5%) had posttraumatic osteoarthritis due to fracture; and 21 (52.5%) had posttraumatic osteoarthritis due to recurrent sprain. Simultaneously, percutaneous Achilles tendon lengthening was € strom procedure on 14 performed on 16 patients (40%), modified Bro (35%), medial displacement calcaneal osteotomy on 3 (7.5%), and subtalar arthrodesis on 3 (7.5%). Deep infection occurred in 1 patient (2.5%), medial malleolar fracture in 1 (2.5%), and insert subluxation in 1 (2.5%) (Table 2). Clinical Outcomes The preoperative and postoperative VAS and AOFAS scores of all patients significantly improved from 7.0 § 2.3 and 53.4 § 17.2 to 2.1 § 2.4 and 94.3 § 13.4, respectively (p < .001 and p < .001). The preoperative and postoperative ankle dorsiflexion and ankle plantarflexion of all patients significantly improved from 6.4° § 5.3° and 19.6° § 9.5° to Table 1 Demographic characteristics of the patients with and without depressive symptoms (N = 40 ankles in 40 patients) Characteristic Age (yr) Sex Body mass index (kg/m2) Complication Follow-up duration (mo)
Depression (n = 13)
No Depression (n = 27)
61.1 9: 4 26.3 § 3.4 1 36.9
61.6 18: 9 25.3 § 2.5 2 34.5
p Value .629 .570 .692 .704 .920
Data presented as mean § standard deviation.
Table 2 Etiology, concurrent procedures, and complications Etiology Primary osteoarthritis Posttraumatic osteoarthritis Recurrent sprain Concurrent procedure Percutaneous Achilles tendon lengthening € strom procedure Modified Bro Medial displacement calcaneal osteotomy Subtalar arthrodesis Complication Deep infection Medial malleolar fracture Insert subluxation Data presented as n (%).
10 (25%) 9 (22.5%) 21 (52.5%) 16 (40%) 14 (35%) 3 (7.5%) 3 (7.5%) 1 (2.5%) 1 (2.5%) 1 (2.5%)
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Table 3 Overall preoperative and postoperative clinical outcomes, ankle ranges of motion, and radiologic parameters (N = 40 ankles in 40 patients)
27.5° § 7.5° in the nondepressive group, respectively; p = .157 and .247) (Table 4).
Item
Preoperative
Final
p Value
Radiographic Outcomes
VAS score AOFAS score Ankle dorsiflexion (°) Ankle plantarflexion (°) TAS (°) TT (°) TLS (°) HD (mm)
7.0 § 2.3 53.4 § 17.2 6.4 § 5.3 19.6 § 9.5 88.4 § 5.4 2.4 § 5.9 78.5 § 6.6 −2.1 § 11.2
2.1 § 2.4 94.3 § 13.4 10.2 § 4.6 25.6 § 7.5 89.6 § 2.5 0.5 § 1.5 86.1 § 2.9 −1.8 § 7.9
<.001* <.001* <.001* <.001* .400 .016* <.001* .754
Data presented as mean § standard deviation. Abbreviations: AOFAS, American Orthopedic Foot and Ankle Society; HD, heel alignment distance; TAS, anterior surface angle of the distal tibia; TLS, lateral surface angle of the distal tibia; TT, talar tilt of the ankle joint; VAS, visual analog scale. * Statistically significant, p < .05.
10.2° § 4.6° and 25.6° § 7.5°, respectively (p < .001 and p < .001) (Table 3). The preoperative and postoperative VAS scores significantly improved from 6.7 § 2.2 to 3.1 § 2.4 in the depressive group and from 7.0 § 1.2 to 1.4 § 2.3 in the nondepressive group (p < .001 and p < .001). The preoperative and postoperative AOFAS scores also significantly improved from 54.4 § 14.2 to 89.3 § 13.4 in the depressive group and from 61.2 § 14.2 to 95.0 § 8.1 in the nondepressive group (p < .001 and p < .001). The preoperative and postoperative ankle dorsiflexion significantly improved from 6.2° § 4.3° to 10.7° § 3.6° in the depressive group and from 6.5° § 3.3° to 9.2° § 2.6° in the nondepressive group (p < .001 and p < .001). The preoperative and postoperative ankle plantarflexion also significantly improved from 19.5° § 4.4° to 24.7° § 6.5° in the depressive group and from 19.9° § 6.5° to 27.5° § 7.5° in the nondepressive group (p < .001 and p < .001) (Table 4). The preoperative VAS and AOFAS scores showed no significant differences (6.7 § 2.2 and 54.4 § 14.2 in the depressive group; 7.0 § 1.2 and 61.2 § 14.2 in the nondepressive group, respectively; p = .154 and .074). However, the postoperative VAS and AOFAS scores were 3.1 § 2.4 and 89.3 § 13.4 in the depressive group and 1.4 § 2.3 and 95.0 § 8.1 in the nondepressive group, respectively, with the nondepressive group showing significantly lower VAS and higher AOFAS scores (p = .031 and p < .001). The preoperative ankle dorsiflexion and plantarflexion showed no significant differences (6.2° § 4.3° and 19.5° § 4.4° in the depressive group; 6.5° § 3.3° and 19.9° § 6.5° in the nondepressive group, respectively; p = .234 and .236). The postoperative ankle dorsiflexion and plantarflexion also showed no significant differences (10.7° § 3.6° and 24.7° § 6.5° in the depressive group; 9.2° § 2.6° and
Table 4 Preoperative and postoperative clinical outcomes and ankle ranges of motion in the patients with and without depressive symptoms (N = 40 ankles in 40 patients) Item
Preoperative VAS score Preoperative AOFAS score Preoperative dorsiflexion (°) Preoperative plantarflexion (°) Final VAS score Final AOFAS score Final dorsiflexion (°) Final plantarflexion (°)
Depression (n = 13)
No Depression (n = 27)
p Value
6.7 § 2.2 54.4 § 14.2 6.2 § 4.3 19.5 § 4.4 3.1 § 2.4 89.3 § 13.4 10.7 § 3.6 24.7 § 6.5
7.0 § 1.2 61.2 § 14.2 6.5 § 3.3 19.9 § 6.5 1.4 § 2.3 95.0 § 8.1 9.2 § 2.6 27.5 § 7.5
.154 .074 .234 .236 .031* <.001* .157 .247
Data presented as mean § standard deviation. Abbreviations: AOFAS, American Orthopedic Foot and Ankle Society; VAS, visual analog scale. * Statistically significant, p < .05.
The preoperative and postoperative TAS and HD showed no significant differences in the overall patients (from 88.4° § 5.4° and −2.1 § 11.2 mm to 89.6° § 2.5° and −1.8 § 7.9 mm, respectively; p = .400 and .754). The preoperative and postoperative TT and TLS showed significant differences in the overall patients (from 2.4° § 5.9° and 78.5° § 6.6° to 0.5° § 1.5° and 86.1° § 2.9°, respectively; p = .016 and p < .001) (Table 3). The preoperative and postoperative TAS and HD showed no significant difference in the depressive group (from 87.4° § 5.3° and −2.1 § 11.3 mm to 89.7° § 2.5° and −1.7 § 7.9 mm, respectively; p = .342 and .542) and in the nondepressive group (from 87.6° § 4.3° and −3.3 § 10.3 mm to 88.9° § 1.2° and −1.3 § 6.3 mm, respectively; p = .346 and .672). Additionally, the preoperative and postoperative TT and TLS changed significantly from 2.4° § 5.8° and 78.5° § 6.5° to 0.5° § 0.7° and 86.1° § 2.9° in the depressive group (p = .021 and p < .001) and from 3.2° § 6.3° and 77.4° § 5.4° to 0.2° § 0.6° and 87.3° § 2.1° in the nondepressive group, respectively (p < .001 and p < .001) (Table 5). The preoperative TAS, TT, TLS, and HD were not significantly different between the groups (87.4° § 5.3°, 2.4° § 5.8°, 78.5° § 6.5°, and −2.1 § 11.3 mm in the depressive group; 87.6° § 4.3°, 3.2° § 6.3°, 77.4° § 5.4°, and −3.3 § 10.3 mm in the nondepressive group, respectively; p = .545, .632, .432, and .765). Additionally, the postoperative TAS, TT, TLS, and HD were not significantly different between the groups (89.7° § 2.5°, 0.5° § 0.7°, 86.1° § 2.9°, and −1.7 § 7.9 mm in the depressive group; 88.9° § 1.2°, 0.2° § 0.6°, 87.3° § 2.1°, and −1.3 § 6.3 mm in the nondepressive group, respectively; p = .841, .821, .621, and .354) (Table 5). Interobserver and Intraobserver Reliabilities Intraclass correlation coefficients with 95% confidence intervals were used to evaluate reliability. A coefficient of 1.0 designates a perfect correlation and >0.8, excellent reliability. The interobserver intraclass correlation coefficients for the TAS, TT, TLS, and HD were 0.945, 0.896, 0.967, and 0.894, respectively. The intraobserver intraclass correlation coefficients for the TAS, TT, TLS, and HD were 0.957, 0.962, 0.943, and 0.902, respectively. Discussion The most important finding of this study is that among the patients who received TAA, the patients with depressive symptoms had poorer postoperative clinical outcomes (VAS and AOFAS scores) than those Table 5 Preoperative and postoperative radiologic parameters in the patients with and without depressive symptoms (N = 40 ankles in 40 patients) Parameter
Depression (n = 13)
No Depression (n = 27)
p Value
Preoperative TAS (°) Preoperative TT (°) Preoperative TLS (°) Preoperative HD (mm) Final TAS (°) Final TT (°) Final TLS (°) Final HD (mm)
87.4 § 5.3 2.4 § 5.8 78.5 § 6.5 −2.1 § 11.3 89.7 § 2.5 0.5 § 0.7 86.1 § 2.9 −1.7 § 7.9
87.6 § 4.3 3.2 § 6.3 77.4 § 5.4 −3.3 § 10.3 88.9 § 1.2 0.2 § 0.6 87.3 § 2.1 −1.3 § 6.3
.545 .632 .432 .765 .841 .821 .621 .354
Data presented as mean § standard deviation. Abbreviations: HD, heel alignment distance; TAS, anterior surface angle of the distal tibia; TLS, lateral surface angle of the distal tibia; TT, talar tilt of the ankle joint.
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without; our hypothesis that patients with depressive symptoms will have worse pain and clinical outcomes after TAA than patients without could be supported. Psychiatric comorbidity is known to be related to medical conditions, such as coronary artery disease, diabetes, and metabolic disease (29,30). Musculoskeletal pain and depressive symptoms have an interactive relationship with each other (1,2,31,32). In particular, there have been reports that depression worsens the severity of musculoskeletal diseases and pain (1). Further, there are reportedly more depressive symptoms in patients with musculoskeletal pain than in those without musculoskeletal pain (1,33). Depression is known to have a negative response to not only the symptoms of musculoskeletal diseases, but also the treatment responses (33). The postoperative VAS score was high in patients with depression, resulting in a high usage of narcotics (33). In the area of orthopedic surgeries, it has been found that depression has a negative relationship with the long-term outcomes of lowerextremity arthroplasty, fracture, and major spine surgeries (5,34,35). These may be because depressive symptoms decreased the satisfaction with surgery and exaggerated the perception of pain and disability (36). In particular, Ellis et al (37) reported that psychopathology, including depressive symptoms, is a factor that lowers the patient-perceived outcome scores 1 year after total knee arthroplasty (TKA). In their study conducted on the outcomes of 79 cases of total hip arthroplasty (THA) for a minimum of 1 years, Riediger et al (38) reported that depression is predictive of lower scores for the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 Health inventory (SF-36). Werner et al (8) conducted a study on the outcomes of 176 cases of total shoulder arthroplasty (TSA) for a minimum of 2 years and reported that preoperative depression is an independent predictor that significantly lowers the post-TSA American Shoulder and Elbow Surgeons score. Previous studies on TKA, THA, and TSA showed that the clinical outcomes are significantly improved even in patients with depression; further, depression is a factor that affects the postoperative clinical outcomes, and evaluating patients’ depressive symptoms is essential before replacement arthroplasty. The cause of the relationship between depression and outcomes after musculoskeletal surgeries is unclear. There is an explanation that selective serotonin reuptake inhibitors or antipsychotics, which are used as treatments for depression, affect the pain pathway (3). Moreover, patients with psychologic distress have the tendency to perceive and express their pain exaggeratedly, make operative decisions at an earlier point of the disease and thus have lower satisfactions with surgery, and express symptoms after surgery actively (5). It has been confirmed that musculoskeletal pains and depressive symptoms have an interactive relationship with each other (31). Recently, the relationship between surgery and depression has been studied in the area of the ankle and foot joints (2,10). Patients with depressive symptoms had higher pain levels before hallux valgus surgery but lower pain levels after surgery than those without; however, the satisfaction regarding pain levels after surgery was very low (10). Thus, it was reported that depressive symptoms had a negative impact on the clinical and functional outcomes of hallux valgus surgery (10). In addition, in a study on psychosocial factors (mood disorder, narcotic usage, tobacco usage, diabetes, and weight) that affect pain after ankle and hindfoot reconstruction, depression and anxiety were reported to increase postoperative pain levels after orthopedic surgeries (2). In the present study, there were no differences in the pre-TAA VAS and AOFAS scores, ankle range of motion, and radiologic parameters between the patients with ankle osteoarthritis with and without depressive symptoms and in the post-TAA ankle range of motion and radiologic parameters. However, the postoperative pain level was significantly higher in the patients with depressive symptoms than in those without, whereas the AOFAS score was significantly lower. Similar to previous studies conducted on total joint arthroplasty, hallux
valgus, and ankle and hindfoot reconstruction surgeries (2), the present study showed that depressive symptoms had negative impacts on the clinical outcomes of the surgery. The study on hallux valgus by Shakked et al (10) and that on TKA by Ellis et al (37) reported that the clinical outcomes of patients with depressive symptoms were also poor; however, there was no relationship between the preoperative clinical symptoms and depressive symptoms in the present study. Accurate evaluation of depressive symptoms was possible in the present study using validated psychiatric depression diagnostic tools, including the CES-D Scale and PHQ-9. However, existing studies conducted on total joint arthroplasty, hallux valgus, and ankle and hindfoot reconstruction surgeries indirectly evaluated depressive symptoms using the Short Form-12 Mental Component Score (SF-12 MCS) based on the finding that the PHQ-9 is correlated with the SF-12 MCS (33,39). Thus, the present study, which assessed depressive symptoms using the CES-D Scale and PHQ-9, was able to measure such more accurately. Our study has the limitations that it has a relatively small sample size and a relatively short mean follow-up duration of 2 years, and that it is a retrospective study. Additional prospective studies on more cases are necessary. There is a report that musculoskeletal pain affects depressive symptoms, and such symptoms decreased after hallux valgus surgery. However, we did not examine the changes in depressive symptoms after TAA in our study; thus, another limitation is that we could not evaluate what effect TAA has on depressive symptoms. However, a single experienced surgeon performed all TAAs with technical consistency in our study. Other existing studies on the effect of depression conducted in the area of orthopedics mainly used the SF-12 MCS, and thus, accurate evaluation of depressive symptoms was difficult. Our study is significant in that it is the first study to use psychiatric diagnostic standards known to be more accurate (CES-D Scale and PHQ-9) to measure depressive symptoms and examine what effects depressive symptoms have on the clinical outcomes after TAA. Although depression was a negative factor of TAA outcomes, the clinical outcomes of the patients with depression still improved after surgery. Based on the study findings, it was confirmed that TAA is a good operative method that improves the clinical outcomes regardless of depressive symptoms. However, evaluating the depressive status of patients before surgery, which is a clinical and radiologic indication of TAA, is thought to be essential in that it provides information to predict the outcomes after surgery. In conclusion, the clinical outcomes after TAA were poor in the patients with depressive symptoms compared with those of the patients without. Because depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA, clinical considerations of such symptoms are essential before TAA.
Supplementary Materials Supplementary material associated with this article can be found in the online version at https://doi.org/10.1053/j.jfas.2019.07.001.
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