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Hip: O. Rolfson, L. E. Dahlberg, J-Å. Nilsson, H. Malchau, and G. Garellick Variables determining outcome in total hip replacement surgery J Bone Joint Surg Br 2009; 91-B: 157-161 [Abstract] [Full text] [PDF]

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Potential non-responders must be identified pre-operatively

Ola Rolfson, Leif E. Dahlberg, Göran Garellick   (16 April 2009)

The relationship between mental anxiety and outcome after primary hip replacement

Munier Hossain, Glynne Andrew   (17 March 2009)

Potential non-responders must be identified pre-operatively 16 April 2009
Ola Rolfson, Orthopaedic Surgeon Dep of Orthopaedics, Inst of Clin Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden, Leif E. Dahlberg, Göran Garellick Send letter to journal: Re: Potential non-responders must be identified pre-operatively ola.rolfson{at}vgregion.se Ola Rolfson, et al.	Sir, We appreciate the comments by Hossain et al where they express concerns about the interpretation of our results regarding the relationship between mental anxiety and outcome after primary hip replacement. The main indications for total hip replacement (THR) are pain and reduced health-related quality of life (HRQoL) due to hip disease. THR is an intervention associated with remarkable pain relief and patient satisfaction, along with outstanding improvements in HRQoL. In addition, as Hossain et al correctly state, 60% of the patients with pre-operative anxiety or depression did not report any problems at follow-up, suggesting that there is also a positive effect of adequate pain management on mental health. However, the focus of this work was not to show an improvement in mental health after joint replacement but to identify variables that are related to poor outcome in the minority of the patients that express discomfort and dissatisfaction following surgery. To do this, we analysed data from the Swedish Hip Arthroplasty Register. In this national observational study we found that pre-operative anxiety/depression in the fifth dimension of the EQ-5D self-classifier significantly predicted poorer outcome with regard to satisfaction and pain relief (adjusting for age, gender, Charnley classification and all other dimensions of the EQ-5D). Then, we performed a post-hoc analysis to investigate the impact of persistent anxiety at one-year follow up. This analysis supported the hypothesis that patients with mental distress report less satisfaction and pain relief. The relationship between mental health and pain is complex and poorly understood. We demonstrated that the patients with anxiety/depression reported higher pre-operative pain and poorer HRQoL than patients without anxiety/depression. This suggests that mental distress may increase the experience of pain, making decisions about the indications for surgery more difficult. Furthermore, from table II it becomes clear that patients with an anxiety/depression score of 2 and 3 pre-operatively and 3 post-operatively reported considerably worse satisfaction as measured with a visual analogue scale (VAS) compared with the mean for all patients in the study. These patients did improve their VAS score for pain without reaching the same level of painlessness as the rest. Our intention is to shed light on this hitherto poorly understood area. We need reliable tools to minimise the number of non-responders and to improve the overall results following THR. We are working on finding instruments to examine psychometric variables that could identify patients who will not benefit from surgery or who need other interventions before surgery. We have no reason to believe that variables that contribute to the experience of pain are different if pain is present in hips, knees, or in the back. However, as we clearly state in the paper, we agree that the appearance of anxiety or depression in patients eligible for THR should not exclude patients from surgery. The awareness of the fact that mental health influences outcome may help us modify the management of these patients before surgery. This includes different combinations of conventional non-surgical treatment options, patient education programmes and in some cases psychotherapy and/or psychoactive drugs. O. Rolfson, Orthopaedic Surgeon, L.E. Dahlberg, G. Garellick, Dept of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
The relationship between mental anxiety and outcome after primary hip replacement 17 March 2009
Munier Hossain, Staf Grade Surgeon Ysbyty Gwynedd, Glynne Andrew Send letter to journal: Re: The relationship between mental anxiety and outcome after primary hip replacement munierh{at}doctors.org.uk Munier Hossain, et al.	Sir, We read this paper with great interest. The authors are to be congratulated for the excellent follow-up reported in their series. We appreciate their efforts to investigate a hitherto unexplored relationship between mental anxiety/depression and outcome following primary hip replacement. Although there are a number of articles scrutinising this relationship following primary knee replacement, we are not aware of any prior account following primary hip replacement to date.1 We do have a major concern with this paper, however, regarding the way in which the data have been interpreted. The principal conclusion of the study is that patients with persistent anxiety/depression have worse outcomes at one year. They acknowledge that “In this study, 60% of the patients with pre-operative anxiety/depression did not report anxiety at their one-year follow-up.” However, they then effectively exclude these patients from post hoc analysis on the basis that patients whose mental status improved reported mental distress pre-operatively due to nervous excitement or unease because of the operation. We would contend that this substantially undervalues the effect of joint replacement surgery on mental health. Simple comparison of the sizes of the groups demonstrates that 1585 previously mentally distressed patients reported an improvement of their mental health to a point where they did not report any problems on the EQ-5D, compared with a group of 1022 patients with persisting mental distress. This would argue that a major effect of the procedure in these patients is improvement in mental distress. As noted by the authors, the principal intention with joint replacement surgery is pain relief. Workers in several other fields of pain management have noted the effect of adequate pain management on mental health. Thus Soin et al2 demonstrated that adequate opioid pain management for chronic non-malignant pain improved mental health and emotional role scores on the SF36. Similarly, there is evidence that surgical treatment of painful conditions improves mental health measured on the SF36 mental health subscale.3 Accordingly, while we would agree that, as with all areas of pain management, attention should be paid to management of mental distress in order to maximise the benefits of treatment, it is simplistic to assert that adequate pain management does not have major benefits in terms of relief of emotional distress. We would recommend that patients should not be excluded from joint replacement surgery on the basis of pre-operative mental distress, as effective pain management may be the best method of improving their mental status. Rolfson et al reported the generic health outcome in patients who presented with mental anxiety but did not show improvement in their mental state after surgery. This paper does not allow us to conclude or predict that the patient who presents with mental anxiety before surgery is more likely to show poor response in the post-operative period. It informs us that the patient who presents with mental anxiety before surgery, but does not show improvement in his/her mental state subsequently, is less likely to be satisfied with surgery and report less health gain and pain relief compared with the patient who does not report mental anxiety either before or after surgery. M. Hossain, Staff Grade Surgeon, G. Andrew, Ysbyty Gwynedd, North West Wales NHS Trust, Gwynedd, UK. 1. Lingard EA, Katz JN, Wright EA, et al. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg [Am] 2004;86-A:2179-86. 2. Soin A, Cheng J, Brown L, Moufawad S, Mekhail N. Functional outcome in patients with chronic nonmalignant pain on long-term opioid therapy. Pain Pract 2008;8:379-84. 3. Lindsay GM, Hanlon P, Smith LN, Wheatley DJ. Assessment of changes in general health status using the short-form 36 questionnaire 1 year following coronary artery bypass grafting. Eur J Cardiothorac Surg 2000;18:557-564.