Shoulder Arthritis Surgery: Depression Complicates Care

CHICAGO — Patients undergoing primary reverse shoulder arthroplasty (RSA) for their glenohumeral osteoarthritis (OA) had more complications of care and higher hospital costs when they also had a diagnosis of depression, new data show.

The abstract was presented Thursday at the American Academy of Orthopedic Surgeons (AAOS) 2022 Annual Meeting.

Dr Keith Diamond

Researchers, led by Keith Diamond, MD, an orthopedic surgeon at Maimonides Medical Center in Brooklyn, New York, queried a private payer database looking for patients who had primary RSA for treatment of glenohumeral OA and also had a diagnosis of depressive disorder (DD) from 2010 through 2019. Patients without DD served as the controls.

After the randomized matching with controls at a 1:5 ratio, the study consisted of 28,410 patients: 4084 in the DD group and 24,326 in the control group.

Researchers found that patients with depression had longer hospital stays (3 vs 2 days, P = .0007). They also had higher frequency and odds of developing side effects within the period of care (47.4% vs 14.7%; odds ratio [OR], 2.27; 95% CI, 2.10 - 2.45, P < .0001).

Patients with depression also had significantly higher rates of medical complications surrounding the surgery and costs were higher ($19,363 vs $17,927, P < .0001).

Pneumonia rates were much higher in patients with DD (10% vs 1.8%; OR, 2.88; P < .0001).

Patients with depression had higher odds of cerebrovascular accident (3.1% vs 0.7%; OR, 2.69, P < .0001); myocardial infarctions (2% vs 0.4%; OR, 2.54; P < .0001); acute kidney injuries (11.1% vs 2.3%; OR, 2.11, P < .0001); surgical site infections (4.4% vs 2.4%; OR, 1.52, P < .0001); and other complications, the authors write.

Diamond told Medscape Medical News there may be a few potential reasons for the associations.

In regard to the strong association with pneumonia, Diamond hypothesized, "Patients with depression can be shown to have lower respiratory drive. If a patient isn't motivated to get out of bed, that can lead to decreased inflation of the lungs."

Acute kidney injury could be linked with depression-related lack of self-care in properly hydrating, he said. Surgical site infections could come from suboptimal hygiene related to managing the cast after surgery, which may be more difficult when patients also struggle with depression.

Asked to comment on Diamond's study, Grant Garrigues, MD, an associate professor at Rush University Medical Center in Chicago, Illinois, and director of upper extremity research, told Medscape the study helps confirm known associations between depression and arthritis.

Dr Grant Garrigues

"We know that people with depression and anxiety feel pain differently," he said. "It might have to do with your outlook — are you catastrophizing or thinking it's a minor inconvenience? It's not that it's just in your head — you physically feel it differently. That is something we're certainly attuned to. We want to make sure the mental health part of the picture is optimized as much as possible."

He added that there is increasing evidence of links between depression and the development of arthritis.

"I'm not saying that everyone with arthritis has depression, but with arthritis being multifactorial, there's a relatively high incidence of symptomatic arthritis in patients with depression," Garrigues said.

"We think it may have something to do with the fight-or-flight hormones in your body that may be revved up if you are living in a stressful environment or are living with a mental health problem. Those will actually change — on a cellular and biochemical basis — some of the things that affect arthritis."

Stronger Emphasis on Mental Health

Diamond said the field needs more emphasis on perioperative state of mind.

"As orthopedic surgeons, we are preoccupied with the mechanical, the structural aspects of healthcare as we try to fix bones, ligaments, and tendons. But I think we need to recognize and explore the connection between the psychiatric and psychological health with our musculoskeletal health."

He noted that in the preoperative setting, providers look for hypertension, diabetes, smoking status, and other conditions that could complicate surgical outcomes and said mental health should be a factor in whether a surgery proceeds.

"If someone's diabetes isn't controlled you can delay an elective case until their HbA1c is under the recommended limit and you get clearance from their primary care doctor. I think that's something that should be applied to patients with depressive disorders," Diamond said.

This study did not distinguish between patients who were being treated for depression at the time of surgery and those not on treatment. More study related to whether treatment affects depression's association with RSA outcomes is needed, Diamond added.

Garrigues says he talks candidly with patients considering surgery about how they are managing their mental health struggles.

"If they say they haven't seen their psychiatrist or are off their medications, that's a nonstarter," he said.

"Anything outside of the surgery you can optimize, whether it's mental health, medical, social situations — you want to have all your ducks in a row before you dive into surgery," Garrigues said.

He added that patients' mental health status may even affect the venue for the patient — whether outpatient or inpatient, where they can get more supervision and help in making transitions after surgery.

Diamond and co-authors and Garrigues have disclosed no relevant financial relationships.

American Academy of Orthopedic Surgeons (AAOS) 2022 Annual Meeting: Abstract 426. Presented March 24, 2022.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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