Mental illness is associated with more pain and worse functional outcomes after ankle fracture

Abstract

Objectives:. To assess clinical and functional outcomes after ankle fracture in patients with preexisting mental illness.
Design:. Retrospective study.
Setting:. Level 1 trauma center.
Patients/Participants:. One thousand three hundred seventy-eight adult patients treated for ankle fractures; 228 (17%) had preexisting mental illness.
Intervention:. Open reduction internal fixation.
Main outcome measure:. Rates of complications and reoperations. Functional outcomes were assessed via Foot Function Index (n = 530) and Short Musculoskeletal Function Assessment (n = 530).
Results:. Depression was the most common mental illness (63%), followed by anxiety (23%). Mental illness was associated with older age, female sex, and preexisting medical comorbidities, including diabetes and obesity. Mental illness was not associated with specific fracture patterns or open injury. Complications occurred no more often in patients with mental illness, but secondary operations (13% vs 7%) were more likely, particularly implant removals (8% vs 4%), both P

Full text

Downloaded from https://journals.lww.com/otainternational by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3gDUFDls0jtSGAoMTFZQW+0ET3qtukTOKt8ywV9Pz4hgYQbB/BcA2SQ== on 05/15/2019
Downloadedfromhttps://journals.lww.com/otainternational by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3gDUFDls0jtSGAoMTFZQW+0ET3qtukTOKt8ywV9Pz4hgYQbB/BcA2SQ== on 05/15/2019
OTAI-D-18-00060; Total nos of Pages: 6;
OTAI-D-18-00060
Mental illness is associated with more pain and
worse functional outcomes after ankle fracture
Natasha M. Simske, BS, Megan A. Audet, BA, Chang-Yeon Kim, MD, Alex Benedick, MD,
Heather A. Vallier, MD∗
Abstract
Objectives: To assess clinical and functional outcomes after ankle fracture in patients with preexisting mental illness.
Design: Retrospective study.
Setting: Level 1 trauma center.
Patients/Participants: One thousand three hundred seventy-eight adult patients treated for ankle fractures; 228 (17%) had
preexisting mental illness.
Intervention: Open reduction internal fixation.
Main outcome measure: Rates of complications and reoperations. Functional outcomes were assessed via Foot Function
Index (n =530) and Short Musculoskeletal Function Assessment (n =530).
Results: Depression was the most common mental illness (63%), followed by anxiety (23%). Mental illness was associated with
older age, female sex, and preexisting medical comorbidities, including diabetes and obesity. Mental illness was not associated with
specific fracture patterns or open injury. Complications occurred no more often in patients with mental illness, but secondary
operations (13% vs 7%) were more likely, particularly implant removals (8% vs 4%), both P<.05. Functional outcomes were worse in
mentally ill patients as measured by the Foot Function Index (39 vs 30, P=.006) and Short Musculoskeletal Function Assessment
Mobility: 45 vs 35, Bothersome: 35 vs 26 and Dysfunction: 35 vs 26, all P<.01.
Conclusion: Secondary operations were nearly 50% more frequent in patients with mental illness, and functional outcome scores
were significantly worse, suggesting that mental illness, unrelated to injury and treatment parameters, has major influence on
outcomes. In the future, strategies to identify and treat mental illness prior to and after treatment could improve functional outcomes
following ankle fracture.
Keywords: ankle, complications, depression, fracture, mental illness, outcomes, psychiatric illness
1. Introduction
Psychiatric and substance use disorders represent a leading cause
of disability in the United States and are prevalent among trauma
populations, with reported rates as high as 42%.
[1–6]
Mental
illness, specifically depression, is associated with poor functional
outcomes, decreased productivity, and worse satisfaction with
care.
[4,6,7–10]
Patients with both orthopaedic injuries and
preexisting mental illness are prone to greater utilization of
care.
[11,12]
The burden of mental illness is often amplified by
negligence of providers without psychiatric specialization.
[13,14]
Traditional management of orthopaedic trauma has focused
on resuscitation and stabilization of injuries to restore function
and quality of life. However, there has been limited investigation
of patients’mental health and its impact on clinical and
functional outcomes. Successful perioperative care may require
treatment modifications and improved access to psychosocial
resources. More evidence is being accumulated to suggest that
mental health concerns may negatively affect postoperative
outcomes. Depression or anxiety is associated with worse clinical
outcomes following total hip and knee arthroplasty,
[15–17]
spine
surgical procedures,
[12,18–20]
hand surgery,
[21]
hip fracture
surgery,
[22]
and other general orthopaedic conditions.
[6]
Evidence
also suggests an increased risk for extremity fractures with
underlying psychiatric comorbidity, due to utilization of
psychotropic medications.
[23–25]
Psychiatric illness may influence pain perception, possibly
impeding functional recovery, while also putting patients at risk
for recidivism.
[4–6,26–29]
Improving general understanding of
mental illness and what impedes clinical and functional recovery
could ameliorate some of these issues. Therefore, the purposes of
this study were to determine the incidence of mental illness in a
large group of patients with ankle fractures, and to evaluate the
impact of mental illness on results and outcomes, as measured by
This study was IRB-approved.
No funds were received in support of this study. No benefits in any form have
been received or will be received from a commercial party related directly or
indirectly to the subject of this article. All of the devices in this manuscript are
FDA-approved.
The authors have no conflicts of interest to disclose.
Supplemental Digital Content is available for this article.
MetroHealth Medical Center, affiliated with Case Western Reserve University,
Cleveland, Ohio
∗
Corresponding author. Address: Department of Orthopaedic Surgery, 2500
MetroHealth Drive, Cleveland, OH 44109. Tel: +216 778 3656; fax: +216 778
4690; e-mail: hvallier@metrohealth.org (Heather A. Vallier).
Copyright ©2019 The Authors. Published by Wolters Kluwer Health, Inc. on
behalf of the Orthopaedic Trauma Association.
This is an open-access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
OTA (2019) e037
Received: 20 December 2018 / Accepted: 26 March 2019
http://dx.doi.org/10.1097/OI9.0000000000000037
Clinical/Basic Science Research Article
OPEN
1

OTAI-D-18-00060; Total nos of Pages: 6;
OTAI-D-18-00060
rates of complications, secondary procedures, and patient-
reported functional outcome scores. We hypothesized that
mental illness would be associated with greater frequency of
complications and worse patient-reported outcome scores.
2. Patients and methods
Following institutional review board approval, a database of
patients with torsional ankle fractures (AO/OTA 44) at an urban
level 1 trauma center was created.
[30]
Between 2003 and 2015,
1378 skeletally mature patients were treated for such injuries.
Charts and radiographs were reviewed for demographic
information, presence of medical comorbidities, and substance
use. Mechanism of injury, fracture pattern, and presence of other
injuries were also recorded. After a minimum of 12 months
functional outcomes were assessed with Foot Function Index
(FFI, n =530) and Short Musculoskeletal Function Assessment
(SMFA) surveys (n =530).
[31,32]
Patients were contacted via
phone on 3 occasions by research staff not involved in clinical
care to complete both surveys; additional attempts to contact
patients were made via mail.
2.1. Mental illness
Patients were subdivided into groups given the presence or
absence of a diagnosed psychiatric disorder at the time of
presentation for ankle fracture (Fig. 1). Conditions were
abstracted from the electronic medical records through electronic
query by a researcher not involved in clinical care. If diagnosis or
treatment of a psychiatric condition was indicated in the
electronic medical record prior to or at the time of injury,
patients were listed as having a positive mental illness history.
Subdivisions were based off of the Diagnostic and Statistical
Manual of Mental Disorders, 5
th
edition (DSM-5) criteria.
[33]
See
Supplemental Digital Content, Appendix, http://links.lww.com/
OTAI/A2 for detailed definitions.
2.2. Treatment
Ankle fractures were treated surgically using standard
techniques of open reduction and internal fixation with the
surgical timing and technique at the discretion of the treating
surgeon. Open fractures were treated with urgent surgical
debridement followed by open reduction and internal fixation
using small fragment and/or mini fragment stainless steel
implants. All patients were splinted postoperatively, and non-
weightbering and elevation were initially recommended. Based
on fracture pattern and clinical and radiographic evidence of
healing, weightbearing was deferred for 6 to 12 weeks after
surgery. Postoperative complications were recorded, including
nonunion, malunion, superficial infection, and deep infection.
Infections were either superficial, treated on an outpatient basis
with local wound care and oral antibiotics; or deep, requiring
surgical debridement and irrigation and intravenous anti-
biotics. Any wound-healing complications were also recorded.
Malunions were described as >5°in any plane and/or residual
medial clear space or syndesmotic widening, and nonunions
were defined as lack of complete healing within 6 months.
Secondary procedures including elective implant removal were
recorded.
2.3. Statistical analysis
Independent sample ttests were used to compare means of
continuous and ordinal variables between patients with mental
illness and those without reported conditions. Pearson chi-
squared tests were used to compare frequencies for categorical
variables between patients with mental illness and those without.
Multiple regression was performed to investigate relationships
between complications or outcome scores (FFI and SMFA) and
patient demographics (age, sex), medical history (obesity,
diabetes, psychiatric illness, tobacco use), and injury features
(pattern, open fracture, and dislocation). Pvalues <.05 were
considered to represent a significant difference.
n=143
62.7%
n=52
22.8%
n=32
14.0%
n=17
7.5% n=9
3.9%
n=10
4.4% n=6
2.6% n=3
1.3%
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Depression Anxiety Bipolar
Disorder
Schizophrenia PTSD Dementia Suicidal
Ideation
OCD
Number of Patients
Psychiatric Disorder
Figure 1. Types of psychiatric illness, diagnosed prior to injury. PTSD =Post-traumatic stress disorder, OCD =obsessive-compulsive disoder.
Simske et al OTA International (2019) e037 www.otainternational.org
2

OTAI-D-18-00060; Total nos of Pages: 6;
OTAI-D-18-00060
3. Results
3.1. Study demographics
One thousand three hundred and seventy-eight patients (708
women and 670 men) were included. Mean age was 46 years and
the average BMI was 31, with 43% of patients considered obese
(BMI>30kg/m
2
) (Table 1). Six hundred fifty-seven patients (48%)
had other medical comorbidities at the time of injury, including
15% with diabetes mellitus. Tobacco, alcohol and recreational
drug use was prevalent. Seven hundred fifty-five patients (58%)
reported use of tobacco products, 601 patients (47%) reported
use of alcohol, and 161 patients (13%) reported recreational drug
use. Alcohol abuse was identified in 68 patients (5%).
3.2. Mental illness
Two hundred twenty-eight patients (17%) had preexisting
mental illness, excluding substance use disorders. Depressive
disorders were the most common (63%), followed by anxiety
disorders (23%), bipolar disorders (14%), and schizophrenia-
spectrum disorders (8%). Additional details are provided in
Figure 1. Comorbidity related to various psychiatric disorders
was common. In this population, 22% of patients had 2 or more
types of diagnosed mental illness with depressive disorders and
anxiety disorders often occurring together (n =28, 57%).
3.3. Subgroup demographics
Patients with mental illness were less likely to be male (72%
female vs 28% P<.001) (Table 1). One hundred nineteen
patients (52%) with mental illness were obese (BMI>30 kg/m
2
),
vs 41% in the other population. Those with preinjury mental
illness were also more likely to be older: 48 vs 45 years (P=.01)
and were more likely to have medical comorbidities: 69% vs
44%, including diabetes: 22% vs 14% (both P<.05). Patients
with mental illness were more likely to abuse alcohol (8% vs. 4%)
and to use recreational drugs (17% vs. 12%), both P<.05.
3.4. Injury characteristics
Mental illness was not associated with specific fracture patterns
or with open fracture (Table 2). However, patients with mental
Table 1
Demographic information, medical comorbidities, and substance use.
All patients (N =1378), (%) Patients with mental illness (N =228), (%) Patients with no mental illness (N =1150), (%) Pvalue
Demographics
Male 670 (48.6) 63 (27.6) 607 (52.8) <.001
Age (years) 45.6 ±17.7 48.3 ±16.8 45.0 ±17.9 .01
BMI 30.9 ±8.7 32.1 ±8.5 30.6 ±8.7 .017
Medical comorbidities
Total 657 (47.7) 157 (68.9) 500 (43.5) <.001
Obesity (BMI>30) 590 (42.8) 119 (52.2) 471 (41.0) .002
Diabetes 212 (15.4) 49 (21.5) 163 (14.2) .025
Substance use
Tobacco 755 (58.3) 137 (62.0) 618 (57.6) .37
Alcohol 601 (46.9) 95 (43.2) 506 (47.7) .74
Alcohol abuse 68 (4.9) 18 (7.9) 50 (4.3) .046
Recreational drugs 161 (12.8) 37 (16.9) 124 (11.9) .047
Table 2
Injury information is provided, including mechanism, fracture pattern, and the presence of open fractures and other injuries.
All patients
(N =1378), (%)
Patients with mental illness
(N =228), (%)
Patients with no mental
illness (N =1150), (%) Pvalue
Injury details
Open 167 (12.1) 25 (11.0) 142 (12.3) .66
Left 634 (46.0) 103 (45.2) 531 (46.2) .83
Weber classification
A 73 (5.3) 12 (5.3) 61 (5.3) 1.00
B 947 (68.7) 161 (70.6) 784 (68.2) .48
C 352 (25.5) 53 (23.2) 299 (26.0) .43
Mechanism of injury
Fall (ground level) 856 (62.1) 168 (73.7) 688 (59.8) <.001
Fall (from height) 49 (3.6) 10 (4.4) 39 (3.4) .44
Altercation 50 (3.6) 6 (2.6) 44 (3.8) .44
Crush 22 (1.6) 1 (0.4) 21 (1.8) .16
MCC/MVC 322 (23.4) 36 (15.8) 286 (24.9) .003
Pedestrian 68 (4.9) 5 (2.2) 62 (5.4) .042
GSW 1 (0.1) 0 (0.0) 1 (0.1) 1.00
Presence of additional injuries
Orthopaedic 355 (25.8) 47 (22.8) 308 (26.3) .45
Nonorthopaedic 163 (11.9) 17 (8.2) 147 (12.6) .13
GSW =gunshot wound, MCC =motorcycle crash, MVC =motor vehicle crash.
Simske et al OTA International (2019) e037 www.otainternational.org
3

OTAI-D-18-00060; Total nos of Pages: 6;
OTAI-D-18-00060
illness were more likely to present with ankle fractures due to a
fall from ground level: 74% vs 60%. Patients with no reported
mental health conditions were significantly more likely to sustain
ankle fracture due to motorized collisions: 25% vs 16%
(P=.017). No differences between groups were seen in the
frequency of other injuries.
3.5. Clinical outcomes
Overall, 181 patients (13%) had a postoperative complication.
Complications occurred no more often in patients with mental
illness (Table 3). One hundred seven patients (7.8%) had a
secondary procedure. Patients with mental illness were more likely
to have implants removed: 8.3% vs 4.4% (P<.001). Implant
removal was primarily for pain relief, but was also performed for
infection and nonunion. Nine patients (39%) with mental illness
were recommended implant removal as a result of unresolved pain,
compared to 29% without mental illness (P=.03).
3.6. Functional outcome scores
Patient-reported functional outcomes, as measured by FFI and
SMFA scores, were distinctly worse for mentally ill patients.
Surveys were completed after mean 70 months follow-up. Scores
were significantly higher (worse) for individuals with mental illness
as shown in Table 4. On the FFI, patients with mental illness
reported significantly greater pain: 40 vs 31 and disability: 47 vs 36
(both P<.01). After multiple regression analysis, mental illness
was found to be a significant positive predictor of FFI disability
(B=7.2, P=.049), indicating that patients with mental illness were
expected to score worse. Similarly, SMFA scores were significantly
higher (worse) for mentally ill patients for all subcategories, except
Arm and Hand (Table 4). Patients with mental health conditions
had higher scores inDaily Activity: 35 vs 26, Emotional Status: 42
vs 34, Mobility: 45 vs 35, Dysfunction: 35 vs 26, and Bothersome:
35 vs 26 when compared alongside patients without (all P<.01).
After regression analysis mental illness remained a significant
positive predictor of SMFA scores for each of the following
subcategories: Daily activity (B=7.5, P=.026), Dysfunction
(B=6.5, P=.017), and Bothersome (B=6.6, P=.034).
4. Discussion
Patients with a prior diagnosis of mental illness realized similar
rates of complications to those without (15% vs. 13%). Yet,
patients with mental illness had substantially worse overall and
subcategory outcome scores on both the FFI and SMFA. Mental
illness was also a predictor of worse outcome scores on multiple
linear regression. This cohort of patients was also more likely to
receive an implant removal, due to pain. If clinical outcomes are
Table 3
Complications and secondary operations.
All patients
(N =1378), (%)
Patients with mental
illness (N =228), (%)
Patients with no mental
illness (N =1150), (%) Pvalue
Secondary procedures
Total 107 (7.8) 28 (12.3) 79 (6.9) .01
Implant removal 70 (5.1) 19 (8.3) 51 (4.4) <.0001
Debridement 5 (0.4) 1 (0.4) 4 (0.3) .60
Revision fixation 22 (1.6) 6 (2.6) 16 (1.4) .24
Arthrodesis 5 (0.4) 1 (0.4) 4 (0.3) .60
Amputation 5 (0.4) 1 (0.4) 4 (0.3) .60
Complications
Total 181 (13.1) 35 (15.4) 146 (12.7) .28
Superficial infection 48 (3.5) 9 (3.9) 39 (3.4) .69
Deep infection 18 (1.3) 4 (1.7) 14 (1.2) .52
Wound healing problem 51 (3.7) 12 (5.3) 39 (3.4) .18
Malunion 19 (1.4) 1 (0.4) 18 (1.6) .34
Nonunion 45 (3.3) 9 (3.9) 36 (3.1) .54
Table 4
Functional outcome scores as measured with the Short Musculoskeletal Function Assessment and Foot Function Index surveys.
All patients (N =1378) Patients with mental illness (N =228) Patients with no mental illness (N =1150) Pvalue
Total respondents (%) 530 (38.5) 101 (44.3) 429 (37.3) .053
Foot function index
Pain 32.4 39.9 30.7 .008
Disability
∗
37.9 46.5 35.9 .003
Activity 25.2 29.7 24.1 .057
Total 32.0 38.7 30.4 .006
Short musculoskeletal function assessment
Daily activity
∗
27.3 35.1 25.6 .002
Emotion 35.0 41.7 33.5 .006
Mobility 37.2 45.2 35.3 .003
Dysfunction
∗
27.4 34.6 25.7 <.001
Bothersome
∗
27.4 34.8 25.7 .002
∗
Indicates survey categories that were still significant (P<.05) following multiple linear regression analysis.
Simske et al OTA International (2019) e037 www.otainternational.org
4

OTAI-D-18-00060; Total nos of Pages: 6;
OTAI-D-18-00060
similar between these populations, why are patients with mental
illness more bothered by their injuries?
Patient satisfaction is highly dependent on a patient’s
perceptions, values, and state of mind.
[9,10,34]
The dynamics of
surgical care, however, are weighted more toward physician
preference.
[35]
Whereas the National Institute of Mental Health
found in 2015 that 18% of US adults have some form of mental
illness, in trauma populations the prevalence has reached as high
as 42%.
[5,36,37]
The pervasiveness of mental illness in these
populations may be an obstacle for achieving reasonable patient
satisfaction, and accordingly, poor patient satisfaction may
adversely affect reimbursement.
We found that patients with mental illness were significantly
more likely to sustain a fall leading to ankle fracture. Suicidal
behavior is often a consequence of psychiatric illnesses, primarily
mood disorders, schizophrenia, and personality disorders.
[38]
Therefore, we attempted to discern if patients with mental illness
were more likely to sustain ankle injury due to high-energy falls,
such as those presenting following nonaccidental jumps. Of the
905 recorded falls, 49 (3.6%) were from a height and this did not
correlate with the psychiatric population. Details obtained within
this retrospective study may have been insufficient to investigate
this possibility.
Operative interventions are often evaluated by complications
defined objectively with clinical and/or radiographic measures.
Functional outcome scores may enhance understanding of
recovery through patients’subjective experience by adjusting
scores based on patient perception of function, pain, and
disability. This allows patients who perceive heightened pain and
functional limitations to rate their recovery as suboptimal,
consistent with our population. Despite similar injury features
and no higher incidence of any complications among persons
with mental illness, they regularly reported worse mean scores
with the FFI and SMFA. Kugelman et al
[39]
observed similar
findings following operative management of tibial plateau
fractures. Their patient population had substantially fewer
persons with mental illness (8.6%) vs 17% in our population.
Our SMFA scores were still comparable to theirs, with similar
subset averages in the Bothersome and Daily activities categories,
while our cohort had lower average function scores (41 vs 35)
and higher average Emotional status (33 vs 42) and Mobility
scores (35 vs 45). Yeoh et al
[40]
observed similar findings, with
clinically depressed patients having significantly worse 36-item
Short Form Health Survey (SF-36) physical component scores
and more disability, as reported by Disability of the Arm,
Shoulder, and Hand scores, over the duration of their recovery.
Mental illness has been found to predominate in populations
with chronic pain, suggesting a potential correlation between
psychiatric disorders and pain.
[41,42]
Pain can also be a key driver
of anxiety and may foster catastrophizing behavior, along with
new or worsening mental illness, principally anxiety, depression,
and posttraumatic stress disorder.
[38,43,44]
Accordingly, comor-
bidity between pain and depression has been reported to
negatively affect outcomes—for example, poor treatment
response and decreased function—when compared to circum-
stances in which only 1 condition presents.
[45,46]
We found that
patients with mental illness were more likely to undergo implant
removals. These patients were also significantly more likely to
report pain as limiting their foot function, a possible reason
underlying why implant removal may have been suggested.
Vincent et al
[47]
reported analogous findings, observing in a
cohort of 101 orthopaedic trauma patients, that those with
depression underwent more surgical procedures and were
readmitted more often for unplanned adverse events. Vialle
et al reasoned that individuals may seek additional medical care
due to perception of amplified pain or exaggerated symptoms,
something that could prevail among individuals with mental
illness who tend to be less satisfied with medical care as a result of
poor coping skills or catastrophizing.
[48,49]
The foremost strength of this study is the extensive number of
patient records reviewed. Our large study population allowed us
to sample a reasonable population size of mentally ill patients
(n =228). As rates of mental illness vary in trauma populations, it
was necessary to obtain a large sample to describe the population
accurately. Due to the retrospective design of our study, it is
possible that preexisting mental illness was underreported due to
potential for unknown diagnosis by patient and/or provider or
failure of providers to report it in the medical record. We also did
not evaluate for potential new or worsened mental illness
following injury. Another weakness of our retrospective study
was the lack of recorded data on the energy associated with
injuries due to a fall. We were also unable to obtain prospective
functional outcome scores from our entire study population. This
represents a possible area for sampling bias to occur, in which
patients experiencing greater pain and discomfort may have felt
more obliged to partake in responding to the FFI and SMFA. This
is a potential risk given the higher response rate in the mentally ill
group (44% vs 37%, P=.053). However, multiple linear
regression still identified psychiatric illness as a predictor of
low functional outcome scores, after controlling for other
variables. It is possible that factors not identified in this study
are influencing the observed association between patients with
mental illness and higher (worse) functional outcome scores.
Although mental illness was not associated with higher rates of
complications, such as infection, nonunion or malunion, patients
with mental illness reported lower functionality and heightened
pain, as indicated by FFI and SMFA scores. This additional
dysfunction was linked to greater resource utilization, with
additional secondary procedures, specifically more implant
removals. This study provides evidence that subjective cognitions
about pain and disability are substantially impacting this
mentally ill population. If patients with ankle fractures who
experience more dysfunction engage in greater resource utiliza-
tion, this can place undo strain on our health care system as a
whole. The authors posit that addressing mental health concerns
during the hospital stay and throughout recovery can help
patients achieve satisfactory functional outcomes, while reducing
potentially unnecessary use of limited hospital resources.
References
1. Ten leading causes of death and injury. Centers for Disease Control,
National Center for Health Statistics website. Available at: https://www.
cdc.gov/injury/wisqars/LeadingCauses.html. Updated April 13, 2018.
Accessed June 6, 2018.
2. Wainberg ML, Scorza P, Shultz JM, et al. Challenges and opportunities
in global mental health: a research-to-practice perspective. Curr
Psychiatry Reports. 2017;19:28.
3. Ferrari AJ, Charlson FJ, Norman RE, et al. Burden of depressive
disorders by country, sex, age, and year: findings from the global burden
of disease study 2010. PLoS Med. 2013;10:e1001547.
4. Muscatelli S, Spurr H, O’Hara N, et al. Prevalence of depression and
posttraumatic stress disorder after acute orthopaedic trauma: a
systematic review and meta-analysis. J Orthop Trauma. 2017;31:47–55.
5. Weinberg D, Narayanan A, Boden K, et al. Psychiatric illness is common
among patients with orthopaedic polytrauma and is linked with poor
outcomes. J Bone Joint Surg Am. 2016;98:341–348.
6. Chrichlow R, Andres P, Morrison S, et al. Depression in orthopaedic
trauma patients. J Bone Joint Surg. 2006;88A:1927–1933.
Simske et al OTA International (2019) e037 www.otainternational.org
5

OTAI-D-18-00060; Total nos of Pages: 6;
OTAI-D-18-00060
7. Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical
outcomes: an evidence-based literature review. J Am Acad Orthop Surg.
2006;14:397–405.
8. Anderson JT, Haas AR, Percy R, et al. Clinical depression is a strong
predictor of poor lumbar fusion outcomes among workers’compensa-
tion subjects. Spine (Phila Pa 1976). 2015;40:748–756.
9. O’Toole RV, Paryavi E, Castillo RC, et al. Is satisfaction among
orthopaedic trauma patients predicted by depression and activation
levels? J Orthop Trauma. 2015;29:e183–e187.
10. Rascoe A, Treiman S, Gunasekar A, et al. Self-reported recovery
likelihood predicts higher physician ratings following orthopaedic
surgery. J Orthop Trauma. 2019;33:e19–e23.
11. Bot GJ, Menendez ME, Neuhaus V, et al. The influence of psychiatric
comorbidity on perioperative outcomes after shoulder arthroplasty. J
Shoulder Elbow Surg. 2014;23:519–527.
12. Walid MS, Robinson JSJr. Economic impact of comorbidities in spine
surgery. J Neurosurg Spine. 2011;14:318–321.
13. Greenberg PE, Fournier AA, Sisitsky T, et al. The economic burden of
adults with major depressive disorder in the United States (2005 and
2010). J Clin Psychiatry. 2015;76:155–162.
14. Grazier KL, Mowbray CT, Holter MC. Rationing psychosocial
treatments in the United States. Int J Law Psychiatry. 2005;28:545–560.
15. Lavernia C, Alceroo J, Brooks L, et al. Mental health and outcomes in
primary total joint arthroplasty. J Arthroplasty. 2012;27:1276–1282.
16. Lingard E, Katz J, Wright E, et al. Predicting the outcomes of total knee
arthroplasty. J Bone Joint Surg Am. 2004;86-A:2179–2186.
17. Singleton N, Poutawera V. Does preoperative mental health affect length
of hospital stay and functional outcomes following arthroplasty surgery?
A registry-based cohort study. J Orthopaedic Surg. 2017;25:1–9.
18. Miller JA, Derakhshan A, Lubelski D, et al. The impact of preoperative
depression on quality of life outcomes after lumbar surgery. Spine J.
2015;15:58–64.
19. Trief PM, Ploutz-Snyder R, Fredrickson BE. Emotional health predicts
pain and function after fusion: a prospective multicenter study. Spine
(Phila Pa 1976). 2006;31:823–830.
20. Tetreault L, Nagoshi N, Nakashima H, et al. Impact of depression and
bipolar disorders on functional and quality of life outcomes in patients
undergoing surgery for degenerative cervical myelopathy. Spine (Phila Pa
1976). 2017;42:372–378.
21. Williams AE, Newman JT, Ozer K, et al. Posttraumatic stress disorder
and depression negatively impact general health status after hand injury.
J Hand Surg Am. 2009;34:515–522.
22. Phillips AC, Upton J, Duggal NA. Depression following hip fracture is
associated with increased physical frailty in older adults: the role of the
cortisol: dehydroepiandrosterone sulphate ratio. BMC Geriatr.
2013;13:60.
23. Kishimoto M, De Hert HE, Carlson P, et al. Osteoporosis and fracture risk
in people with schizophrenia. Curr Opin Psychiatry. 2012;25:415–429.
24. Cizza G, Primma S, Coyle M, et al. Depression and osteoporosis: a
research synthesis with meta analysis. Hormone Metabolic Res.
2010;42:467–482.
25. Bruyere O, Reginster JY. Osteoporosis in patients taking selective
serotonin reuptake inhibitors: a focus on fracture outcome. Endocrine.
2015;48:65–68.
26. Becher S, Smith M, Ziran B. Orthopaedic trauma patients and
depression: a prospective cohort. J Orthop Trauma. 2014;10:242–246.
27. Beleckas CM, Prather H, Guattery J, et al. Anxiety in the orthopedic
patient: using PROMIS to assess mental health. Qual Life Res.
2018;27:2275–2282.
28. Koleszar JC, Childs BR, Vallier HA. The prevalence of recidivism in
trauma patients. Orthopaedics. 2016;39:300–306.
29. Brooke BS, Efron DT, Chang DC, et al. Patterns and outcomes among
penetrating trauma recidivists: it only gets worse. J Trauma. 2006;61:
16–19.
30. Meinberg E, Agel J, Roberts C, et al. Fracture and Dislocation
Classification Compendium-2018. J Orthop Trauma. 2018;32 (suppl
1): S1–S170.
31. Budiman-Mak E, Conrad KJ, Roach KE. The foot function index: a
measure of foot pain and disability. J Clin Epidemiol. 1991;44:561–570.
32. Martin DP, Engelberg R, Agel J, et al. Development of a musculoskeletal
extremity health status instrument: the Musculoskeletal Function
Assessment instrument. J Orthop Res. 1996;14:173–181.
33. American Psychiatric AssociationDiagnostic and Statistical Manual of
Mental Disorders, 5th ed. Arlington, VA: American Psychiatric
Publishing; 2013.
34. Knutsen E, Paryavi E, Castillo R, et al. Is satisfaction among orthopaedic
trauma patients predicted by depression and activation levels? J Orthop
Trauma. 2015;29:e183–e187.
35. Kennedy GD, Tevis SE, Kent KC. Is there a relationship between patient
satisfaction and favorable outcomes? Ann Surg. 2014;260:592–600.
36. McCarthy ML, MacKenzie EJ, Edwin D, et al. Psychological distress
associated with severe lower-limb injury. J Bone Joint Surg Am.
2003;85:1689–1697.
37. Holbrook TL, Anderson JP, Sieber WJ, et al. Outcome after major
trauma: discharge and 6-month follow-up results from the Trauma
Recovery Project. J Trauma. 1998;45:315–323.
38. Oquendo MA, Baca-Garcia E, Mann JJ, et al. Issues for DSM-V: suicidal
behavior as a separate diagnosis on a separate axis. J Psychiatry.
2008;165:1383–1384.
39. Kugelman D, Qatu A, Haglin J, et al. Impact of psychiatric illness on
outcomes after operatively managed tibial plateau fractures (OTA-41).
J Orthop Trauma. 2018;32:e221–e225.
40. Yeoh JC, Pike JM, Slobogean GP, et al. Role of depression in outcomes of
low-energy distal radius fractures in patients older than 55 years.
J Orthop Trauma. 2016;30:228–324.
41. Bennun IS, Bell P. Psychological consequences of road traffic accidents.
Med Sci Law. 1999;39:167–172.
42. Connaughton J, Patman S, Pardoe C. Are there associations among
physical activity, fatigue, sleep quality and pain in people with mental
illness? A pilot study. J Psychiatr Ment Health Nurs. 2014;21:738–745.
43. Castillo RC, Wegener ST, Heins SE, et al. Longitudinal relationships
between anxiety, depression, and pain: results from a two-year cohort
study of lower extremity trauma patients. Pain. 2013;154:2860–2866.
44. Lee CH, Choi CH, Yoon SY, et al. Posttraumatic stress disorder
associated with orthopaedic trauma: a study in patients with extremity
fractures. J Orthop Trauma. 2015;29:e198–e202.
45. Bair MJ, Robinson RL, Katon W, et al. Depression and pain
comorbidity: a literature review. Arch Intern Med. 2003;163:
2433–2445.
46. Holmes A, Christelis N, Arnold C. Depression and chronic pain. Med J
Aust. 2013;199:S17–S20.
47. Vincent HK, Hagen JE, Zdziarski-Horodyski LA, et al. Patient-reported
outcomes measurement information system outcome measures and
mental health in orthopaedic trauma patients during early recovery.
J Orthop Trauma. 2018;32:467–473.
48. Gatchel RJ, Peng YB, Peters ML, et al. The biopsychosocial approach to
chronic pain: scientific advances and future directions. Psychol Bull.
2007;133:581–624.
49. Vialle E, de Oliveira Pinto BM, Vialle LR, et al. Evaluation of
psychosomatic distress and its influence in the outcomes of lumbar fusion
procedures for degenerative disorders of the spine. Eur J Orthop Surg
Traumatol. 2015;25:S25–S28.
Simske et al OTA International (2019) e037 www.otainternational.org
6