Patient Literature Abstracts

Obey and Miller, “Resources for Patient Mental Health and Well-Being after Orthopaedic Trauma.” 

• Problem: Addresses the impact of psychiatric disorders, such as depression, anxiety, and PTSD, on patient outcomes following orthopaedic trauma and emphasizes the need for comprehensive mental health support alongside physical rehabilitation.
• Focus: To highlight and discuss the various resources available to support the mental health and well-being of patients recovering from orthopaedic trauma.
• Study / Data Population: Reviewed literature and resources available nationally and locally for psychiatric illness management in orthopaedic trauma patients.
• Parameters measured: Outlined various types of resources including psychological treatments (CBT, mindfulness), spiritual support, trauma-informed care, support groups, and referral options.
• Key results: Outlined the effectiveness of psychological treatments, patient satisfaction with spiritual support, and the impact of trauma-informed care on patient outcomes.
  • Psychological treatments: CBT was found effective in reducing symptoms of depression and anxiety.
  • Spiritual support: Showed positive impacts on coping mechanisms and patient satisfaction. 
  • Trauma-informed care: Improved patient trust and engagement in treatment.
  • Support groups: Provided peer support and shared experiences.
  • Referral options: Varied by effectiveness based on patient engagement and follow-through.
• Limitations: Under-recognition and undertreatment of psychiatric disorders by non-specialist providers, systemic and financial barriers to accessing mental health care, and variability in the utilization of trauma-informed care programs like the Trauma Survivors Network.  Specific barriers to resource utilization such as financial constraints, geographical limitations, and the need for better integration of these resources into orthopaedic care pathways were also mentioned.

Zdziarski-Horodyski et al., “An Integrated-Delivery-of-Care Approach to Improve Patient Reported Physical Function and Mental Wellbeing after Orthopedic Trauma

• Problem: Despite available psychosocial support, acute trauma care often neglects ongoing emotional and physical needs of orthopedic trauma patients, potentially leading to poorer outcomes. This study addresses whether an integrated care (IntCare) approach, which combines physical rehabilitation with structured psychosocial support, can improve functional quality of life (QOL) and emotional wellbeing compared to standard care (UsCare).
• Focus: The study evaluates the effectiveness of IntCare in improving patient outcomes, including physical function, emotional wellbeing, medical complications, and hospital readmissions, in comparison to UsCare.
• Study/Data Population:
  • Inclusion Criteria: Orthopedic trauma patients.
  • Sample Size: 100 participants, randomized into IntCare or UsCare groups.
  • Parameters Measured:
  • Primary Outcomes: Lower Extremity Gain Scale (LEGS), handgrip strength, and active range of motion (AROM).
  • Secondary Outcomes: Patient-reported outcomes (PROMIS™ measures), medical complications, readmissions, and onset of new co-morbid diseases.
  • Psychosocial Measures: PTSD Checklist, BDI-II, STAI, and Tampa Scale of Kinesiophobia-11.
• Key Results:
  • IntCare vs. UsCare: IntCare is hypothesized to improve functional QOL and emotional wellbeing, reduce medical complications, hospital readmissions, and incidence of psychological illness more than UsCare. 
  • Primary Findings: The use of integrated care is expected to provide a holistic approach to patient recovery, combining physical rehabilitation with psychosocial support, potentially leading to better overall outcomes.
• Limitations:
  • Potential positive bias due to the control group's perception of receiving additional care.
  • Strict adherence to the intervention may be challenging without compensation for participants.
  • Possible interference with the control group’s outcomes due to frequent interactions for data collection.

Stinner, Hendrickson, and Vallier, “Trauma System Support to Facilitate Recovery.” 

• Problem: Trauma, a leading cause of death and disability, imposes substantial healthcare costs and impacts recovery beyond physical injury. Despite advances in acute trauma care, psychosocial factors influencing recovery are under-addressed.
• Focus: Reviews trauma centers' programs and resources aimed at promoting psychosocial recovery and identifies barriers to implementing such programs.
• Study/Data Population: Examines existing trauma recovery programs including the Trauma Survivors Network (TSN), Trauma Collaborative Care Study (TCCS), Center for Trauma Survivorship (CTS), and Trauma Recovery Services (TRS). It also considers barriers to implementation.
• Parameters Measured: Programs were assessed on their ability to provide psychosocial support, improve mental health outcomes, enhance patient satisfaction, and reduce healthcare utilization. Metrics included adherence to treatment, patient satisfaction, mental illness screening, and emergency department utilization.
• Key Results: Trauma recovery programs have shown potential benefits including improved patient self-efficacy, reduced emergency department visits, better adherence to treatment, and increased satisfaction. However, variability in resource use and implementation affected the consistency of results. Recent updates to trauma center requirements by the American College of Surgeons (ACS) are expected to drive further integration of psychosocial support.
• Limitations: Barriers to effective implementation include lack of formal support within trauma systems, limited provider education, and resource constraints. The variability in program effectiveness and engagement also poses challenges.
• Conclusion: Addressing psychological and social factors in trauma recovery is crucial for optimizing long-term outcomes. Enhancing trauma center resources and education on psychosocial support will benefit patients and improve overall recovery efficiency.

Brahmbhatt D, Schpero WL. Access to Psychiatric Appointments for Medicaid Enrollees in 4 Large US Cities. JAMA. Published online July 31, 2024. doi:10.1001/jama.2024.13074 

• Problem: Medicaid enrollees face a disproportionate burden of severe mental illness yet psychiatrists are less likely than other physicians to accept insurance especially medicaid- this limits access to mental health resources for some of those that need it most
• Focus: Limited availability and wait times for adult appts with psychiatric prescribing clinicians- particularly among medicaid enrollees
  • Study/ Data population: Randomly selected 80 prescribing clinicians among 4 major cities of New York City, Los Angeles, Chicago and Phoenix (total of 3220 clinicians)- called as medicaid enrollees seeking soonest avail appointment
  • Parameters measured: examined appointment availability, wait times and reasons an appt could not be make with the sampled clinician
• Key results:
  • Of 320 clinician offices called, 87 (27.2%) had appts available
  • Median wait times were 11 days in Phoenix, 23 days in Chicago, 28 days in New York, and 64 days in LA
  • On largest medicaid managed care plans across 4 of largest US cities, only 17.8% of clinicians listed as in-network for medicaid were reachable, accepted medicaid and could provide a new patient appt—when access did exist, was often not timely w wait times up to 6 months
• Limitations:
  • Lack of comparison group of enrollees with commercial health insurance
  • Calls were placed only to practices in urban areas and diagnosis for appt request when prompted was depression
  • Results may not generalize to rural areas or patients seeking for other conditions

Vranceanu et al., “How Do Orthopaedic Surgeons Address Psychological Aspects
of Illness?”

• Problem: Despite the known impact of psychological factors on pain and disability in orthopaedic patients, orthopaedic surgeons have not fully integrated biopsychosocial models into their practices. This work aims to explore orthopaedic surgeons' attitudes and practices regarding the identification, discussion, and referral of psychological issues in their patients.
• Focus: The behaviors and attitudes of orthopaedic surgeons towards
  psychological aspects of patient care, including noticing, screening, discussing,
  and referring patients for psychological treatment and investigates barriers to
  these practices and variations based on surgeon characteristics.
• Study/Data Population: 350 orthopaedic surgeons from the Science of Variation Group (SOVG) and the Ankle Platform.
• Parameters Measured:
  • Degree to which surgeons notice, screen, discuss, and refer psychological
    illnesses.
  • Surgeon characteristics: age, gender, research and teaching engagement, specialization, country of practice.
  • Barriers to referring patients for psychological treatment.
• Key Results:
  • Surgeons showed a tendency to notice and discuss psychological issues, with mean Likert-scale scores of 4.3 and 3.9, respectively.
    o Screening for psychological illness was less frequent, with a mean score of 3.2.
  • Surgeons who engaged in research were more likely to refer patients for psychological treatment (P=0.05).
  • Surgeons in South America were more likely to refer patients for
    psychological treatment compared to those in North America and Europe.
  • Barriers to referral included lack of time, stigma, and discomfort, with the least significant barriers being concern for reputation or conflicts with colleagues.
  • Depression and anxiety were the most common reasons for referral, while issues like lack of social support were less commonly referred.
• Limitations:
  • Selection bias due to the subgroup nature of the survey population (SOVG and Ankle Platform).
  • Limited generalizability, particularly for surgeons outside of America and
    Europe.
  •  Small sample size in some regions could affect the representativeness of the findings.
• Conclusion: While orthopaedic surgeons generally notice and discuss
  psychological factors, they are less likely to screen or refer patients for
  psychological treatment. The primary barriers include lack of time, stigma, and
  discomfort with the referral process. To improve integration of psychosocial care,
  surgeons should focus on enhancing communication skills and empathy,
  addressing these barriers, and incorporating biopsychosocial models into their
  practice.

Stinner and Mir, “Patient Mental Health and Well-Being.”

Outcomes

• Problem: Addresses the impact of mental health and well-being on orthopaedic trauma outcomes, emphasizing the need for comprehensive patient care beyond biomedical models.
• Focus: Focused on how mental health conditions such as PTSD, depression, and anxiety influence recovery and functional outcomes in orthopaedic trauma patients.
• Study / Data population: Included various prospective observational studies and clinical data from patients undergoing orthopaedic trauma treatment, examining psychological factors and their impact on recovery.
• Parameters measured: Prevalence of PTSD, depression, and anxiety postinjury, correlations between mental health conditions and pain intensity, function, and patient satisfaction.
• Key results: High prevalence rates of PTSD (20%-51%) and depression (21%) post-injury, significant associations between anxiety and pain persistence, and correlations showing worse outcomes with higher pain catastrophizing and lower self-efficacy.
• Limitations: Include potential biases in self-reported data, variations in psychological screening methods, and challenges in implementing routine mental health screenings in orthopaedic practice.

Sharma et al., “Mental Health in Patients Undergoing Orthopaedic Surgery.”

• Outcomes
• Problem: Addresses the impact of mental health factors on patients undergoing orthopaedic surgery, aiming to understand how psychosocial variables influence surgical outcomes and patient satisfaction.
• Focus: Focuses on assessing the relationship between psychosocial factors (such as anxiety, depression, pain catastrophizing) and outcomes in orthopaedic surgery patients. It explores the prevalence, impact, and management of these factors throughout the surgical process.
• Study / Data population: Includes data from various orthopaedic patient populations, covering conditions like hand disabilities (e.g., carpal tunnel syndrome, trigger finger), foot and ankle disorders (e.g., hallux valgus), and orthopaedic oncology (e.g., soft tissue and bone tumors).
• Parameters measured:
  • Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores
  • Michigan Hand Questionnaire (MHQ) scores
  • Various psychosocial screening tools (e.g., Beck Anxiety Inventory, Beck Depression Inventory, Pain Catastrophizing Scale)
  • Patient-reported outcomes related to pain, function, and quality of life (e.g., SF-36 health survey)
• Key results:
  • Positive correlation between higher DASH scores and depression across different diagnoses (p < 0.01).
  • Impact of poor coping strategies and depressive symptoms on MHQ scores.
  • Association between hallux valgus severity and reduced SF-36 health survey component scores.
  • Higher rates of carpal tunnel syndrome associated with anxiety, depression, and poorer mental and physical functioning.
• Limitations:
  • Potential biases in self-reported psychosocial data.
  • Difficulty in establishing causality due to the observational nature of many studies.
  • Variability in psychosocial assessment tools and their application across different patient groups.
  • Challenges in implementing routine psychosocial screenings in orthopaedic practice due to time constraints and resource availability.

Michaels et al., “Traditional Injury Scoring Underestimates the Relative
Consequences of Orthopedic Injury.”

• Problem: The long-term functional, social, psychological, and financial impacts of orthopedic injuries compared to non-orthopedic injuries are not well-understood. Existing trauma scoring systems focus on acute outcomes but do not fully capture long-term disability.
• Focus: Aims to evaluate the comprehensive impact of orthopedic injuries on various domains of life over a 12-month period, comparing outcomes with non-orthopedic injuries. It examines physical, social, psychological, and financial aspects to identify differences and long-term effects.
• Study / Data Population: Included 165 patients, aged 18-65, who sustained injuries requiring hospitalization. Of these, 61% had orthopedic injuries (ORTHO) and 39% had non-orthopedic injuries (nonORTHO). Patients were assessed at baseline, 6 months, and 12 months post-injury.
• Parameters measured:
  • Physical function (SF36: physical function, role-physical, bodily pain)
  • Social function (SF36: social function)
  • Psychological outcomes (Beck Depression Inventory, Impact of Events Scale, Civilian Mississippi Scale for PTSD)
  • Financial and occupational impact (return to work, financial difficulties, legal issues)
  • Substance use (sedatives, analgesics, cocaine products)
• Key results:
  • ORTHO patients had significantly worse outcomes in physical function, role-physical, and bodily pain at 6 and 12 months compared to nonORTHO patients.
  • At 12 months, ORTHO patients also exhibited worse scores in social function, mental health, and occupational function.
  • Fewer ORTHO patients had returned to work (56% vs. 79%, p = 0.034) and more experienced financial difficulties (56% vs. 27%, p = 0.017).
  • ORTHO patients reported higher symptoms of depression, stress disorder, and substance abuse. They had significantly higher scores on the Beck Depression Inventory (p = 0.002), Impact of Events Scale (p = 0.002), and Civilian Mississippi Scale for PTSD (p = 0.04).
  • ORTHO patients experienced more negative impacts on personal relationships and social support compared to nonORTHO patients.
• Limitations:
  • The study’s sample size limits generalizability and raises concerns about type II errors, particularly regarding the differentiation between multiple orthopedic injuries and less complex injury patterns.
  • The analysis is secondary and focused on associations rather than causation, making it challenging to establish definitive causal relationships between orthopedic injuries and long-term outcomes.

Rogers et al., “How Mental Health Affects Injury Risk and Outcomes in
Athletes.”

• Problem: Mental health issues significantly impact athletic performance and injury risk. Athletes face unique challenges related to mental health, which can affect their physical health and performance outcomes. This article explores how mental health conditions are linked to increased injury risk and poorer recovery and identifies barriers to effective mental health care for athletes.
• Focus: The article investigates the relationship between mental health conditions and athletic performance, examining how psychological factors contribute to injury risk and recovery. It also addresses the barriers athletes face in seeking and receiving appropriate mental health care.
• Study / Data Population: Elite athletes, including collegiate and professional levels, across various sports.
• Specific Population:
  • OCD: Among 269 collegiate athletes, 17% screened positive for OCD.
  • Depression: Approximately 24% of collegiate athletes have clinically depressive symptoms, according to CES-D scores.
• Parameters measured:
  • Incidence and prevalence of mental health disorders in athletes.
  • Correlation between mental health symptoms and injury risk.
  • Impact of mental health on athletic performance and recovery.
  • Barriers to mental health care, including stigma and logistical challenges.
• Key results:
  • Prevalence of Depression and Eating Disorders: High rates of depression and disordered eating are noted, with depression affecting 24% of collegiate athletes. The prevalence of disordered eating behaviors is also significant, though specific percentages are not provided.
  • Injury Risk: Athletes with mental health conditions, such as ADHD, are more prone to injuries. Symptoms of ADHD and depression are associated with increased injury rates and longer recovery periods.
  • Physiological Impact: Mental health conditions can disrupt physiological responses, making athletes more susceptible to injuries. For instance, ADHD is linked to reduced axonal integrity, which could contribute to higher concussion risks.
• Barriers to Care:
  • Stigma: 88% of mental health clinicians document their findings in separate medical records, complicating confidentiality and communication.
  • Medication Concerns: Athletes are concerned about the impact of medications on performance and compliance with governing body regulations.
  • Lack of Resources: Only 39% of NCAA programs have a formal mental health screening plan, and less than half use screening methods for disordered eating, depression, or anxiety.
• Limitations:
  • Variability in Data: The variability in study methodologies and populations affects generalizability.
  • Underutilization of Resources: Standardized screening and treatment protocols are lacking, and mental health services are often not integrated well within athletic programs.
  • Stigma and Confidentiality: Stigma and confidentiality concerns can prevent athletes from seeking necessary care.

Kugelman et al., “Impact of Psychiatric Illness on Outcomes After Operatively Managed Tibial Plateau Fractures (OTA-41).”

• Problem: The impact of psychiatric illness on long-term functional outcomes after surgical repair of tibial plateau fractures.
• Focus: To evaluate how self-reported psychiatric conditions influence functional outcomes and pain levels following operatively managed tibial plateau fractures.
• Study/Data Population: Prospective cohort study conducted over 11 years at an academic medical center. 245 patients with tibial plateau fractures were included, of which 21 reported treatments for a psychiatric diagnosis.
• Parameters Measured: Functional outcomes (using Short Musculoskeletal Function Assessment (SMFA)), pain scores (Visual Analog Scale (VAS)), and postoperative complications (infection, VTE, nonunion, need for secondary operations) were assessed at 3 months, 6 months, and long-term follow-up (mean = 18 months).
• Key Results: Patients with psychiatric diagnoses reported higher pain scores and worse long-term functional outcomes. At 6-month follow-up, they showed poorer results in SMFA function subgroups. At long-term follow-up, these patients had significantly worse SMFA scores, increased pain scores, and no difference in postoperative complications compared to those without psychiatric diagnoses. Psychiatric diagnosis was an independent predictor of worse functional outcomes.
• Limitations: Potential underreporting of psychiatric conditions, reliance on self-reported data, and lack of information on current psychiatric treatment or the development of posttraumatic stress disorder (PTSD). The study's findings may not fully represent all patients with psychiatric illnesses.

Wright et al., “What Is the Impact of Social Deprivation on Physical and Mental Health in Orthopaedic Patients?”

• Problem: The effect of social deprivation on physical function, pain interference, depression, and anxiety in orthopaedic patients.
• Focus: To assess how social deprivation, based on zip code data, affects patient-reported outcomes in orthopaedic care and whether this impact varies across different orthopaedic subspecialties.
• Study/Data Population: Cross-sectional analysis of 7,500 new adult patients presenting to an orthopaedic center between August 1, 2016 and December 15, 2016. Patients completed PROMIS assessments for physical function, pain interference, depression, and anxiety. Social deprivation was measured using the Area Deprivation Index.
• Parameters Measured: PROMIS Physical Function-v1.2, Pain Interferencev1.1, Depression-v1.0, and Anxiety-v1.0 scores. Differences between the most-deprived and least-deprived quartiles were analyzed.
• Key Results: Patients from highly deprived areas had significantly worse scores across all PROMIS domains compared to those from less deprived areas (physical function: mean difference 4, p < 0.001; pain interference: mean difference -4, p < 0.001; depression: mean difference -5, p < 0.001; anxiety: mean difference -6, p < 0.001). Subspecialties such as foot/ankle, joint reconstruction, sports medicine, and upper extremity showed significant differences based on social deprivation, while spine, oncology, and trauma subspecialties did not.
• Limitations: Cross-sectional design limits causal inferences. The impact of specific interventions on improving outcomes in socially deprived populations was not examined. The generalizability of the findings may be restricted to similar orthopaedic settings.

Vincent et al., “Patient-Reported Outcomes Measurement Information System Outcome Measures and Mental Health in Orthopaedic Trauma Patients During Early Recovery.”

• Key takeaway: Patients with depression or anxiety need additional psychosocial support during acute care to improve overall physical and emotional recovery after trauma.
• Problem: The impact of mental health symptoms, specifically depression and anxiety, on patient-reported outcomes in orthopaedic trauma patients during early recovery is not well understood. This study examines the relationships between these negative affective states, physical/functional status, and emotional well-being.
• Focus: Investigated how depression and anxiety affect Patient-Reported Outcomes Measurement Information System (PROMIS) measures of Physical Function, Psychosocial Illness Impact—Positive, and Satisfaction with Social Roles and Activities during the early recovery period following orthopaedic trauma.
• Study/Data Population: 101 orthopaedic trauma patients (average age 43.6 years, 40.6% women) who were followed from acute care through weeks 2, 6, and 12 post-discharge. The patients were recruited from a Level-1 trauma center and had severe or multiple orthopaedic injuries requiring at least one surgical procedure. Exclusion criteria included pre-existing psychiatric diagnoses and current use of psychotropic medications.
• Parameters Measured: PROMIS measures included Physical Function, Psychosocial Illness Impact—Positive, and Satisfaction with Social Roles and Activities. Additionally, the Beck Depression Inventory-II (BDI-II) and the State-Trait Anxiety Inventory (STAI) were used to assess depression and anxiety. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and the number of surgeries performed.
• Key Results: By week 12, 20.9% of patients reported moderate-to-severe depression and 35.3% reported significant anxiety. Depressed patients had longer hospital stays, more complex injuries, and higher readmission rates. Physical Function and Satisfaction with Social Roles and Activities improved by 40% and 22.8% respectively, but improvements were attenuated in patients with anxiety. Depression and anxiety were associated with lower Psychosocial Illness Impact—Positive scores. Specifically, patients with high depression and anxiety scores showed decreased Psychosocial Illness Impact—Positive by 4.9% and 5.1% over time, respectively.
• Limitations: The use of a single trauma center, which may affect generalizability, and potential bias from excluding patients with pre-existing psychiatric conditions. Additionally, the loss of participants by the 12-week time point might bias results, though the characteristics of dropouts were similar to those who remained.

Flanigan, Everhart, and Glassman, “Psychological Factors Affecting Rehabilitation and Outcomes Following Elective Orthopaedic Surgery.”

• Problem: Psychological factors significantly influence pain perceptions, rehabilitation compliance, and outcomes following elective orthopaedic surgeries, such as total joint arthroplasty (TJA), anterior cruciate ligament reconstruction (ACLR), and spine surgery.
• Focus: Reviews the impact of psychological traits on surgical outcomes and discusses strategies for psychological optimization to improve postoperative rehabilitation and recovery.
• Study/Data Population: Includes studies on patients undergoing TJA, ACLR, and spine surgery, focusing on psychological factors such as pain perception, self-efficacy, optimism, stress, and social support.
• Parameters Measured: Psychological traits (e.g., pain catastrophizing, kinesiophobia, self-efficacy), rehabilitation compliance, pain perception, functional outcomes, and patient satisfaction.
• Key Results:
  • Pain Perception: Fear-avoidance behavior and pain catastrophizing negatively affect postoperative recovery and rehabilitation.
  • Self-efficacy and Optimism: Higher levels of self-efficacy and optimism are associated with better rehabilitation compliance and improved outcomes.
  • Depression and Stress: High levels of preoperative stress and depression are linked to worse postoperative outcomes, though surgery often improves these symptoms. Social support can buffer these effects.
  • Intervention Strategies: Cognitive-behavioral therapy, goal setting, motivational interviewing, and peer support are effective in addressing psychological issues affecting rehabilitation.
• Limitations: Does not detail specific interventions for all psychological traits and the effectiveness of these strategies may vary among individuals.

Castillo et al., “Association Between 6-Week Postdischarge Risk Classification
and 12-Month Outcomes After Orthopedic Trauma.”

• Problem: Identifying how risk and protective factors at 6 weeks post-injury classify patients into clusters that predict 12-month functional and health outcomes.
• Focus: To examine if early risk and protective factors can classify patients into clusters that account for variations in long-term outcomes.
• Study/Data Population: 352 patients with severe orthopedic injuries.
  • Inclusion Criteria: Patients from 6 US level I trauma centers, aged 18-60, with significant orthopedic injuries.
  • Study Period: July 16, 2013 - January 15, 2016.
  • Analysis Period: October 9, 2017 - July 13, 2018.
• Parameters Measured:
  • Risk Factors: Pain intensity, depression, PTSD, alcohol abuse, tobacco use.
  • Protective Factors: Resilience, social support, self-efficacy for return to activity, self-efficacy for managing financial recovery.
  • Outcomes at 12 Months: Function (SMFA), depression (PHQ-9), PTSD, self-rated health.
• Key Results:
  • Clusters Identified: Six distinct clusters, collapsible into four clinical groups from low risk/high protection to high risk/low protection.
  • Outcomes: All outcomes worsened from the best to the worst group. The SMFA scores differed significantly between groups (e.g., best vs. second group: 7.8 points difference).
  • Implications: Early classification into risk clusters can guide personalized post-surgical care and resource allocation.
• Limitations:
  • Loss to Follow-Up: Some patients were lost to follow-up, which might affect the results.
• Cluster Identification: Variability in determining optimal cluster numbers could affect the classification's precision.

Kang et al., “The Psychological Effects of Musculoskeletal Trauma.”

• Problem: Musculoskeletal injuries lead to chronic pain, disability, opioid dependence, and increased rates of depression, anxiety, and PTSD, which are often underdiagnosed and undertreated in orthopedic trauma patients.
• Focus: To examine the prevalence and impact of psychological disorders following musculoskeletal trauma and identify early interventions to improve patient outcomes.
• Study/Data Population: General adult population with musculoskeletal injuries. Specific reference to severe lower-limb injury patients from the Lower Extremity Assessment Project (LEAP).
• Parameters Measured
  • Prevalence of depression, anxiety, and PTSD post-trauma.
  • Predictive factors for chronic pain and disability.
  • Impact of resilience, social support, and coping skills on recovery.
  • Use of mental health services post-injury.
• Key Results
  • Depression and PTSD prevalence post-trauma: 32.6% and 20-51%, respectively.
  • Psychological factors predict long-term pain and disability, independent of injury severity.
  • LEAP study: 50% of severe lower-limb injury patients had psychological conditions 3 months post-injury, with minimal mental health service use.
  • Protective factors like resilience and social support improve recovery; interventions such as CBT, mindfulness, and coping skills training show positive outcomes.
  • Early high pain intensity, sleep dysfunction, and depression strongly predict chronic pain.
  • Pain catastrophizing and depressive symptoms correlate with higher pain levels and functional impairment.
  • Low resilience and self-efficacy are linked to prolonged work disability and poor recovery outcomes.
• Limitations
  • Lack of routine psychological assessment and intervention in orthopedic trauma care.
  • Potential underreporting of psychological distress due to stigma and inadequate screening.
• Key Takeaways
  • Early psychological assessment and intervention in orthopedic trauma patients can significantly improve long-term outcomes.
  • Raising awareness among orthopedic surgeons about the psychological impact of trauma is crucial for comprehensive patient care.
  • Implementing validated screening tools and providing access to psychological services should be integral to trauma treatment protocols.

Kirven et al., “Interventional Efforts to Reduce Psychological Distress after
Orthopedic Trauma.”

• Problem: Orthopedic trauma often results in significant psychological distress, adversely affecting patient recovery and outcomes. Identifying and implementing effective interventions to reduce this distress is crucial.
• Focus: The systematic review aims to identify and evaluate various treatment options to mitigate psychological distress in patients following orthopedic trauma, including screening tools, counseling, rehabilitation, and interventions targeting long-term psychological health.
• Study/Data Population: Various studies involving orthopedic trauma patients who underwent interventions such as mind-body skills training, cognitive-behavioral therapy, psychosocial support programs, and rehabilitation.
• Parameters Measured
  • Disability (SMFA)
  • Pain (NAS)
  • Coping and mood (PCS, PAS, CES-D, PTSD)
  • Anxiety, self-efficacy
  • Psychiatric complaints
  • PTSD, depression
  • Functional limitations
  • Pain scores
  • Mobility
  • Mental health outcomes
  • Surgeons' confidence in managing psychosocial concerns
• Key Results
  • Mind-body skills and cognitive-behavioral strategies significantly improved disability, pain, coping, mood, and other psychological measures.
  • Self-efficacy–enhancing educational interventions reduced anxiety and increased self-efficacy.
  • Psychosocial support programs lowered psychiatric complaints and improved quality of life.
  • Collaborative care and stepped care interventions reduced PTSD and alcohol misuse/dependence.
  • Multidisciplinary interventions led to better pain management and fewer primary care visits.
  • Amputation was found to reduce PTSD risk compared to limb salvage in military populations.
  • Surgeons' confidence in managing psychosocial issues increased with collaborative care programs.
• Limitations
  • Lack of studies focusing solely on long-term psychological distress post-intervention.
  • Many studies did not measure intervention effects specifically.
  • The unexpected nature of orthopedic trauma makes research challenging.
  • Differences between civilian and military populations may affect generalizability.
• Conclusions: Effective screening tools and identification of risk factors are crucial for managing psychological distress in orthopedic trauma patients. Interventions such as mind-body skills training, cognitive-behavioral therapy, psychosocial support, and multidisciplinary rehabilitation have shown positive outcomes. Surgeon confidence in managing these issues is essential for appropriate referral and treatment. Further research is needed to develop holistic and effective treatments for this population.

Roșca et al., “Psychological Consequences in Patients With Amputation of a Limb. An Interpretative-Phenomenological Analysis.”

Patients after limb amputation experience emotional impact, negative effects, tendency toward isolation, role constraints and limitations, phantom limb pain, and emotional balancing.

• Problem: study explores the psychological consequences of limb amputation and emphasizes the need for tailored interventions and support plans for amputees.
• Focus: The research aims to identify the psychological impact of limb amputation and propose effective strategies for medical professionals to support affected individuals.
• Study/Data Population: The study employs an idiographic analysis of a small sample of amputees, focusing on their personal experiences and psychological adjustments.
• Parameters Measured: Psychological impact, adjustment processes, and the effectiveness of group psychotherapy and multidisciplinary interventions.
• Key Results:
  • Group psychotherapy enhances independence, acceptance, and rehabilitation in amputees.
  • Understanding the phenomenology of psychological consequences aids in improving therapeutic efficacy.
  • Awareness among medical staff about the trauma, loss, and suffering associated with amputation fosters empathy and compassionate care.
  • Multidisciplinary teams and frameworks such as Self psychology and Self-determination theory (SDT) can provide valuable insights into patient needs and improve intervention strategies.
• Limitations:
  • Small sample size limits the generalizability of findings across different demographics and amputation types.
  • Short time frame since amputation restricts exploration of long-term adjustment themes. Follow-up studies are needed to assess long-term outcomes.

“Rehabilitation and the Long-Term Outcomes of Persons with Trauma-Related
Amputations - ScienceDirect.”

• Problem: The study investigates the factors influencing the number of inpatient rehabilitation nights and the long-term outcomes of patients with trauma-related amputations.
• Focus: The analysis explores demographic and clinical factors affecting rehabilitation use and examines the impact of inpatient rehabilitation on health and vocational outcomes.
• Study/Data Population: Patients with trauma-related lower limb amputations treated at the University of Maryland Shock Trauma Center. The study focuses on a sample of 146 patients who were alive, located, and agreed to participate in interviews.
• Parameters Measured: Number of inpatient rehabilitation nights, SF-36 scale outcomes (physical component summary, role physical, bodily pain, vitality, role emotional), vocational outcomes (return to work, reduced hours of work).
• Key Results:
  • Older patients and those with more severe injuries spent more nights in rehabilitation.
  • Women, non-whites, and more educated patients spent more time in inpatient rehabilitation.
  • Inpatient rehabilitation significantly improved physical and vocational outcomes, including decreased bodily pain, better physical functioning, increased return to work, and reduced hours of work.
  • Racial differences persisted in outcomes despite higher utilization of rehabilitation services by non-whites.
• Limitations: Only analyzing data from a single trauma center -- may not generalize to all traumatic amputees. Additionally, the retrospective nature of the study, along with potential recall bias, may affect the results.

Weinberg et al., “Psychiatric Illness Is Common Among Patients with Orthopaedic Polytrauma and Is Linked with Poor Outcomes.”

• Title: Psychiatric Illness Is Common Among Patients with Orthopaedic Polytrauma and Is Linked with Poor Outcomes
• Problem: Psychiatric disorders are often underdiagnosed and undertreated by non-mental health providers. Emerging evidence suggests that psychiatric illnesses have negative effects on recovery following various medical procedures, including orthopaedic surgeries. Despite this, limited data exist regarding outcomes in patients with psychiatric disorders who sustain multiple-system orthopaedic trauma.
• Focus: Investigates the prevalence of psychiatric disorders in patients with orthopaedic polytrauma, how well these disorders are identified and managed, and their impact on surgical outcomes, including the risk of postoperative complications.
• Study Population:
  • 332 Patients
  • 238 males (71.7%) and 94 females (28.3%)
  • Mean age: 39 ± 16 years
  • Racial demographics: 65.1% Caucasians, 31.3% African-Americans, 3.6% other races
• Parameters Measured:
  • Injury characteristics:
    • Mean Injury Severity Score: 27 ± 12 points
    • Mean Body Mass Index: 29.5 ± 7.9 kg/m²
    • Types of fractures:
      • 171 femur fractures, 56 acetabular fractures, 70 pelvic ring fractures, 6 cervical spine fractures, 73 thoracolumbar spine fractures
  • Psychiatric Disorders (Prevalence):
    • Depression: 74 patients (22.3%)
    • Substance abuse: 56 patients (16.9%)
    • Other psychiatric conditions: Anxiety, bipolar disorder, dementia, ADHD, schizophrenia, etc. (varied prevalence)
    • Patients with two or more psychiatric diagnoses: 43 patients
  • Identification of Psychiatric Disorders by Physicians:
    • Psychiatric disorders were identified in 69.2% of the patients with such diagnoses.
    • Identification rate was significantly lower in orthopedic surgery patients (10%) compared with trauma surgery patients (74.2%).
  • Restarting Home Psychiatric Medications:
    • 71.4% of patients had their psychiatric medications restarted within 24 hours.
    • Rate significantly lower in orthopedic surgery patients (20%) compared with trauma surgery patients (79.1%).
  • Follow-up Recommendations:
    • 39.2% of patients were instructed to follow up with a mental health-care provider.
    • Rate significantly lower in orthopedic surgery patients (10%) compared with trauma surgery patients (41.7%).
  • Postoperative Complications:
    • 19.9% of patients experienced at least one postoperative complication.
    • Depression and dementia were significant predictors of complications.
    • Other conditions such as substance abuse did not show significant associations with complications.
• Key Results:
  • Psychiatric disorder prevalence: 31.3% of patients had psychiatric illnesses, with depression as the most common (22.3%).
  • Psychiatric disorders significantly increased the likelihood of complications:
    • Depression was an independent predictor of postoperative complications (OR = 2.956, p = 0.002).
    • Male sex and higher Injury Severity Scores were also predictors of complications.
• Limitations:
  • Substance abuse and tobacco use were analyzed separately, which may affect how psychiatric comorbidities were understood in relation to complications.
  • Psychiatric disorder recognition was lower in the orthopedic service, possibly underestimating the true burden.

Helmerhorst et al., “Risk Factors for Continued Opioid Use One to Two Months After Surgery for Musculoskeletal Trauma.”

• Title: Risk Factors for Continued Opioid Use One to Two Months After Surgery for Musculoskeletal Trauma
• Problem: Opioid use post-operatively is common, yet its long-term effectiveness and impact on recovery are debated. There is limited data on opioid use beyond the acute phase, particularly regarding psychological factors influencing opioid dependence after musculoskeletal trauma.
• Focus: This study investigates the relationship between psychological factors and continued opioid use one to two months after musculoskeletal trauma surgery. It examines if factors like catastrophic thinking, depression, anxiety, and PTSD influence opioid use during the subacute recovery phase.
• Study/Data Population:
  • Inclusion Criteria: English-speaking patients aged 18 or older with operatively treated musculoskeletal trauma.
  • Exclusion Criteria: Major medical comorbidities, chronic pain conditions, significant cognitive or psychiatric issues, secondary gain factors, and cognitive limitations.
  • Sample Size: 145 patients who completed questionnaires about opioid use one to two months post-surgery.
• Parameters Measured:
  • Psychological Factors: Center for Epidemiologic Studies Depression Scale (CES-D), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale (PASS-20), PTSD Checklist (PCL-C).
  • Pain and Disability: Numeric Rating Scale (NRS) for pain, Short Musculoskeletal Function Assessment Questionnaire (SMFA).
  • Injury Severity: Abbreviated Injury Scale (AIS).
• Key Results:
  • Opioid Use: 28% of patients used opioids one to two months postsurgery.
  • Psychological Correlates: Higher levels of catastrophic thinking (PCS), anxiety (PASS-20), depression (CES-D), and PTSD (PCL-C) were associated with continued opioid use (p < 0.001).
  • Disability and Pain: Greater pain and disability were noted in patients still using opioids (p < 0.001).
  • Multivariable Analysis: Catastrophic thinking was the most significant predictor of continued opioid use (OR 1.12 [95% CI 1.07-1.18], p < 0.001). A model including pain with activity explained 34% of the variance in opioid use.
• Limitations:
  • Prospective study.
  • Relied on self-reported opioid use and nonstandard thresholds for psychological disorders.
  • The AIS may not adequately reflect injury severity.
  • Cross-sectional data cannot establish causation.
• Conclusion: Psychological factors, particularly catastrophic thinking, are strongly associated with continued opioid use after musculoskeletal trauma surgery. This suggests that addressing psychological distress and ineffective coping strategies may be more beneficial than prolonged opioid use. Future research should explore integrated biopsychosocial models and strategies to reduce opioid dependency through psychological support.

Vincent et al., “Psychological Distress After Orthopedic Trauma.”

• Problem: Orthopedic trauma is an unforeseen life-changing event that can cause significant psychological distress, including post-traumatic stress syndrome, depression, and anxiety, which interfere with functional recovery and quality of life.
• Focus: Examines the prevalence of psychological distress in orthopedic trauma patients, potential interventions to reduce distress, and the implications for rehabilitation and long-term recovery
• Study population: Survivors of orthopedic trauma, including those with multiple fractures and amputations.
• Parameters measured:
  • Prevalence of psychological distress (post-traumatic stress syndrome, depression, anxiety)
  • Effectiveness of interventions for distress reduction
  • Impact on rehabilitation participation and outcomes
  • Long-term psychological and physical health outcomes
• Key results:
  • Over 50% of orthopedic trauma survivors experience psychological distress that can last for decades after physical recovery.
  • Early identification and intervention for psychological distress can provide necessary resources and support.
  • Effective short-term interventions include holistic approaches, pastoral care, coping skills, mindfulness, peer visitation, and educational resources.
  • Long-term strategies that enhance recovery include connecting survivors to support networks and facilitating support groups (e.g., Trauma Survivors Network).
  • Rehabilitation specialists play a crucial role in optimizing patient outcomes by advocating for and participating in these strategies.
• Limitations: There is variability in the effectiveness of interventions based on individual patient circumstances and types of trauma.

Muscatelli et al., “Prevalence of Depression and Posttraumatic Stress Disorder After Acute Orthopaedic Trauma.”

• Problem: The psychological impact of acute orthopaedic trauma, specifically the prevalence of depression and posttraumatic stress disorder (PTSD), is underexplored despite its potential to significantly affect patient outcomes and recovery.
• Focus: To synthesize and quantify the prevalence of depression and PTSD among patients with acute orthopaedic injuries and identify potential predictors and associated factors for these conditions.
• Study/Data Population: The review included 27 studies (1991-2014) with 7109 patients who sustained acute orthopaedic injuries. Studies included those focusing on fractures of the appendicular skeleton or pelvis. Excluded were case reports and narrative reviews.
• Parameters Measured: Prevalence of depression and PTSD, with subgroup analyses by sex, injury type, service status, assessment duration, and study country.
• Key Results:
  • Depression prevalence: 32.6% (95% CI, 25.0–41.2) among 6005 patients.
  • PTSD prevalence: 26.6% (95% CI, 19.0–35.9) among 1867 patients.
  • Combined prevalence of both depression and PTSD: 16.8% (95% CI, 9.0–29.4) among 443 patients.
  • Female patients were four times more likely to experience PTSD than males (OR: 4.36, 95% CI, 1.82–10.43).
  • Patients with lower extremity fractures had a higher likelihood of PTSD (OR: 2.31, 95% CI, 1.03–5.17).
  • Depression prevalence was higher in military personnel (40.3%) compared to civilians (29.8%), while PTSD prevalence was similar across these groups.
• Limitations:
  • Predominance of cross-sectional studies with limited longitudinal data.
  • Variability in diagnostic metrics and follow-up periods.
  • Incomplete data on variables like ethnicity, comorbidities, and preexisting mental health conditions.
• Conclusion: Highlights a high prevalence of depression and PTSD among orthopaedic trauma patients, suggesting a need for improved screening and management strategies to address these psychological conditions effectively. Future research should focus on longitudinal studies and interventions to enhance patient outcomes.

Brown, “Mental Health Implications and Psychologic Factors in Workers’ Compensation Cases.”

“The authors found that workers with musculoskeletal workplace injuries had a higher likelihood of experiencing mental illness according to the K6 scale, but were less likely to receive mental health services.' Twenty-nine percent of the injured workers in the study met the criteria for serious mental illness”

• Problem: The article addresses the significant impact of psychiatric services on the return-to-work (RTW) outcomes of injured workers, highlighting the need for mental health interventions in the workers' compensation system.
• Focus: To evaluate the effect of psychiatric services on RTW rates, the prevalence of serious mental illness among injured workers, and the benefits of workplace interventions.
• Study/Data Population: The article synthesizes findings from multiple studies, including longitudinal studies following injured workers for up to 18 months post-injury, and systematic reviews evaluating workplace interventions.
• Parameters Measured:
  • RTW rates among injured workers using psychiatric services vs. those who did not.
  • Prevalence of serious mental illness (K6 scale score of 13 or greater).
  • Delay in accessing mental health services post-injury.
  • Perception of justice during workers' compensation claims.
  • Long-term psychological effects of occupational injuries.
• Key Results:
  • Injured workers using psychiatric services had lower RTW rates compared to those who did not use such services.
  • A delay of more than 3 months in accessing mental health services post-injury is common.
  • 29% of injured workers met criteria for serious mental illness, but fewer than half received mental health services.
  • Factors such as perceived injustice, severity of injury, and lack of work consistency correlate with poorer mental health outcomes.
  • Workplace interventions, including multifaceted RTW programs, significantly reduce lost work time and improve mental health outcomes.
• Limitations:
  • Lack of data on pre-existing mental health conditions.
  • Limited research directly linking workplace injury to mental health outcomes.
  • Difficulty in quantifying mental health issues compared to physical injuries.
  • Need for baseline mental health assessment during initial injury evaluation.
• Conclusion: Early intervention, supportive services, and clear communication among employers, insurers, and healthcare providers are crucial in managing the mental health of injured workers, reducing lost work time, and improving RTW outcomes. Comprehensive workplace interventions can mitigate long-term psychological effects and enhance overall recovery and job function.

Mckechnie and John, “Anxiety and Depression Following Traumatic Limb Amputation.” Prevalence; amputation

• Problem: The prevalence of anxiety and depression among post-traumatic amputees is unclear due to contradictory and inconsistent findings in existing research.
• Focus: This review aims to synthesize available research on the levels of anxiety and depression in post-traumatic amputees, considering different assessment tools and follow-up periods.
• Study/Data Population:
  • Six studies assessed anxiety levels, using three different diagnostic scoring systems with follow-up periods ranging from two to 53 years.
  • Nine studies assessed depression levels, using five different scoring systems with follow-up periods ranging from two to 53 years.
  • Specific populations include UK military personnel, veterans of Vietnam and Iraq/Afghanistan, and general amputee populations.
• Parameters Measured:
  • Anxiety levels using HADS, ICD 9, DSM IV.
  • Depression levels using HADS, ICD 9, DSM IV, CES-D, and SF 36 subset.
  • Employment status, substance abuse, relationship problems, and quality of life (QOL) in relation to amputation.
• Key Results:
  • Anxiety levels varied between 25.4% to 57%, while depression levels ranged from 20.6% to 63%.
  • Studies using HADS found higher anxiety and depression scores in patients with chronic pain compared to those without.
  • Melcer's prospective study showed the highest diagnosis rates within the first six months post-operation.
  • Reiber found no significant difference in depression levels between Vietnam and Iraq/Afghanistan veterans but highlighted pain as a significant factor affecting QOL.
  • Dharm-Dhatta reported high employment retention rates in the UK military, while Hawandeh found all patients with depression were unemployed.
  • Substance abuse was relatively low compared to the general population, but relationship issues were prevalent, with varying divorce and marriage rates post-amputation.
• Limitations:
  • Significant heterogeneity in assessment tools and follow-up periods, preventing meta-analysis.
  • Potential publication bias and selection bias due to specialized samples and voluntary participation.
  • Limited generalizability to all traumatic amputees, particularly civilian populations.
  • Variability in healthcare services and follow-up durations across studies.
• Conclusions:
  • Post-traumatic amputees exhibit higher levels of anxiety and depression than the general population.
  • Routine screening for mood disorders in amputees should be considered.
  • Further research is needed to understand the long-term mental health outcomes and the impact of different rehabilitation and support services on this population.

Ostlie et al., “Mental Health and Satisfaction with Life among Upper Limb Amputees.”

• Rehabilitation of upper limb amputees should emphasize facilitating return to work and preventing short- and long-term complications for maintenance of acceptable life satisfaction.
• Upper limb amputees have significantly lower life satisfaction compared to the general population, mainly due to changes in occupational status and complications related to amputation.
  • Full Title: Mental health and satisfaction with life among upper limb amputees: a Norwegian population-based survey comparing adult acquired major upper limb amputees with a control group
  • Problem: Investigates the psychological and social impacts of upper limb amputation, focusing on the role of various mediators such as occupational status, physical activity, social support, and post-amputation complications.
  • Focus: The study compares mental health and perceived satisfaction with life among adult acquired major upper limb amputees in Norway with a control group from the Norwegian general population.
  • Study/Data Population (including inclusion criteria):
    • Amputee group: Adult acquired major upper limb amputees in Norway.
    • Inclusion criteria: Age >18 years, resident in Norway, mastering spoken and written Norwegian, acquired upper limb loss through the radiocarpal joint or proximal of this level.
    • Exclusion criteria: Severely reduced cognitive function or general condition.
    • Control group: Randomly drawn from the National Population Register (DSP).
    • Inclusion criteria: Age >18 years, resident in Norway, mastering spoken and written Norwegian.
• Parameters Measured:
  • Life satisfaction (Satisfaction With Life Scale, SWLS)
  • Mental health (Hopkins Symptom Check List 25-item, SCL-25)
• Key Results:
  • Amputees scored significantly lower on life satisfaction than the control group.
  • A tendency to poorer mental health in the amputee group was observed, but no clear evidence of such a difference.
  • The amputation effect on life satisfaction was mainly mediated by changes in occupational status and the occurrence of short- or long-term complications related to the amputation.
  • Importance of Rehabilitation: Emphasizing measures that facilitate return to work in upper limb amputee rehabilitation is crucial for the amputees’ well-being and physical function. Suggests that interventions focused on helping amputees return to work are likely to improve their quality of life and mental health.
  • Anxiety levels in the amputee group were consistent with general population rates, while depression levels were somewhat lower than some previous studies but still indicative of potential concerns.
  • Physical activity and social support had limited mediator effects due to methodological limitations and statistical power issues.
• Limitations:
  • The study is cross-sectional, limiting the ability to infer causality.
  • High percentage of missing data for SCL-25.

Lee et al., “Posttraumatic Stress Disorder Associated With Orthopaedic Trauma.”

• Problem: PTSD is a significant mental health issue that can occur after trauma or life-threatening events, commonly recognized among soldiers and now increasingly noted among civilian trauma populations, including orthopaedic trauma patients. The prevalence and risk factors for PTSD among orthopaedic trauma patients need to be better understood.
• Focus: This study aimed to determine the prevalence of PTSD in young male military conscripts who experienced extremity long-bone fractures and to evaluate the association between injury-related variables and the development of PTSD.
• Study/Data Population: The study included 447 men older than 18 years who had one or more acute long-bone extremity fractures treated operatively within 12 months of recruitment, assessed at the Seoul Regional Military Manpower Center from March 2013 to March 2014. The final sample consisted of 148 individuals after applying exclusion criteria and accounting for non-participation.
  • Inclusion Criteria: Men older than 18 years with acute long-bone extremity fractures treated operatively within 12 months
  • Exclusion Criteria:
    • Preexisting psychological disorders
    • Traumatic head injury
    • Chest or abdominal injury requiring hospital treatment
    • Spine or pelvic bone fracture
    • Extremity fracture in the hand or foot
    • Completion of elementary or middle school only
• Parameters Measured
  • PTSD symptoms using the Korean version of the posttraumatic disorder scale (PDS)
  • Demographic and clinical data (injury mechanism, fracture location and multiplicity, fracture severity, joint involvement, secondary osteoarthritis, pain VAS score, and EAIS score)
• Key Results
  • The prevalence of PTSD in the study population was 27.0% (40 of 148 individuals).
  • Multivariate logistic regression analysis identified lower extremity fracture, multiple extremity fractures, and higher pain VAS scores as significantly related to the occurrence of PTSD.
• Limitations
  • The study population was limited to young men, which may not generalize to the broader population.
  • PTSD evaluation occurred at a mean of 12.37 months post-injury, which may not capture long-term PTSD progression.
  • The study excluded patients with hand or foot fractures and had a small sample size for open fractures.
  • No universally accepted criteria for grading posttraumatic osteoarthritis were applied across all joints.
  • Psychological factors other than pain were not considered.
• Conclusion: The study found a 27.0% prevalence of PTSD among young men with extremity fractures, with lower extremity fractures, multiple fractures, and higher pain VAS scores being significant predictors. Clinicians should address both physical and psychological needs for optimal recovery, and early psychological interventions could reduce pain intensity and PTSD prevalence.

Aaron et al., “Posttraumatic Stress Disorders in Civilian Orthopaedics.”

• Title: Posttraumatic Stress Disorders in Civilian Orthopaedics
• Problem: Posttraumatic stress disorder (PTSD) is an anxiety disorder that may develop after exposure to traumatic events. Although much research focuses on military populations, PTSD also occurs in civilian orthopaedic patients following various musculoskeletal injuries. This disorder can adversely affect patient outcomes in orthopaedics, including rehabilitation and overall satisfaction.
• Focus: Reviews the prevalence, effects, and management of PTSD in civilian orthopaedic patients. It highlights the need for orthopaedic surgeons to recognize and address PTSD to improve patient outcomes.
• Study/Data Population:
  • Ursano et al examined 164 patients (122 motor vehicle accident victims, 42 controls); PTSD rates at 1, 3, and 6 months.
  • National Study on the Costs and Outcomes of Trauma: 2,707 patients with Abbreviated Injury Scale score >3; PTSD symptoms measured at 3 and 12 months.
  • Michaels et al: 100 patients with Injury Severity Score (ISS) of 13.7; PTSD measured at 6 months.
  • Starr et al: 580 patients with musculoskeletal injuries from various accidents; PTSD measured using the Revised Civilian Mississippi Scale.
• Lower Extremity Assessment Project: 569 patients at eight level I trauma centers; assessed psychosocial and physical recovery.
• Parameters Measured:
  • PTSD prevalence and symptom clusters (reexperiencing, avoidance, hyperarousal)
  • Functional outcomes (e.g., ADLs, SF-36 scores)
  • Psychological measures (e.g., BSI, MCEPS)
  • Impact of PTSD on physical rehabilitation and patient satisfaction
• Key Results:
  • PTSD prevalence varies with injury type and mechanism, with significant rates found among trauma patients (e.g., 34.4% at 1 month post-motor vehicle accident, 20.7% at 12 months post-trauma).
  • PTSD negatively impacts functional outcomes, including ADLs and return to work. PTSD is associated with increased impairment and lower overall health scores.
  • Both adult and pediatric populations show substantial impacts from PTSD, with poorer mental health and physical outcomes reported.
• Limitations:
  • Variability in measurement instruments and diagnostic criteria
  • Differences in study populations and follow-up durations
  • Potential biases in self-reported data
• Summary: PTSD is a significant concern for civilian orthopaedic patients, with substantial impacts on rehabilitation and overall outcomes. Orthopaedic surgeons need to be aware of PTSD risk factors and symptoms to effectively prevent and manage this condition. Early recognition and intervention can improve patient outcomes by addressing the emotional and functional consequences of trauma. Further studies are needed to explore effective management strategies and their impact on musculoskeletal recovery.

Haupt et al., “Pre-Injury Depression and Anxiety in Patients with Orthopedic Trauma and Their Treatment.”

• Title: Pre-injury Depression and Anxiety in Patients with Orthopedic Trauma and Their Treatment
• Problem: Depressive symptoms negatively impact outcomes following musculoskeletal injury, but the prevalence of pre-injury depression and anxiety in orthopedic trauma patients and their treatment during hospitalization is not well-documented.
• Focus: Aims to determine the pre-injury prevalence of psychiatric diagnoses (depression and anxiety), medication lapses, and the use of psychiatric consult services among patients admitted for orthopedic trauma.
• Study/Data Population: 4053 patients admitted to the orthopedic trauma service from 2010-2015.
• Parameters Measured:
  • Pre-injury psychiatric diagnoses (depression, anxiety).
  • Use of psychotropic medications and delays in receiving them.
  • Receipt of new psychotropic medications during hospitalization.
  • Psychiatric consultation use.
  • Injury Severity Scores (ISS).
  • Length of ICU stay and total hospital length of stay (LOS).
• Key Results:
  • o 3.8% of patients had documented pre-injury depression (80%) or anxiety (30%).
  • Patients with pre-existing depression or anxiety had a 32% longer LOS (p < 0.016).
  • Nearly two-thirds of patients with pre-existing psychotropic medication experienced a delay (median = 1 day, range 0-14 days).
  • 16% of patients received new psychotropic medications during hospitalization; antipsychotics (8/16), anxiolytics (3/16), and antidepressants (1/16).
  • 16.7% of patients with pre-existing psychiatric conditions received a psychiatric consult. These patients had higher ISS, longer ICU stays, and longer hospital LOS (all p < 0.05).
• Limitations:
  • The prevalence of depression and anxiety is likely under-reported compared to national data.
  • Data are retrospective and may not fully capture the prevalence or impact of psychiatric conditions.

Becher, Smith, and Ziran, “Orthopaedic Trauma Patients and Depression.”

• Title: Orthopaedic Trauma Patients and Depression: A Prospective Cohort
• Problem: Depression is prevalent in orthopedic trauma patients and affects functional recovery. Understanding its prevalence, risk factors, and natural history in this population is limited, which hinders effective management and treatment.
• Focus: Evaluates the prevalence of depression in orthopedic trauma patients, assesses risk factors related to depression in the acute period, and tracks the natural history of depression over time. It hypothesizes that the severity of orthopedic trauma correlates with increased levels of depression throughout the recovery process.
• Study/Data Population: Initially 110 Orthopedic trauma patients admitted to Atlanta Medical Center, follow-up data from 48 patients.
• Parameters Measured:
  • Depression: Assessed using the Patient Health Questionnaire (PHQ-9).
  • Social Support and Stress: Measured with the Duke Social Support and Stress Scale (DUSOCS).
  • Demographic and Injury Data: Including age, sex, ISS scores, number of limbs injured, ICU admission, and history of psychiatric conditions, alcohol, tobacco, or drug use.
  • Follow-Up: Depression and social support were reassessed 8-10 months after injury.
• Key Results:
  • 53% of patients experienced depression of any severity; 20% had moderate depression and 10% had moderate-to-severe depression.
  • Depression scores slightly decreased over 9 months but remained high. Medicaid patients had a significant increase in depression scores (average increase of 6.33 points, p = 0.02) compared to insured or uninsured patients.
  • A history of psychiatric illness, unemployment, low social support, and illicit drug use were significant predictors of higher depression scores at follow-up. Severity of injury did not correlate with depression severity.
  • Depression scores were higher in patients with pre-existing psychiatric conditions and elevated scores at injury.
• Limitations:
  • Low follow-up rate (51%).
  • Lack of control for brain trauma subsets. Inability to determine pre-injury depression rates.
  • No intervention arm to assess impact of psychological counseling or medication.

Crichlow et al., “Depression in Orthopaedic Trauma Patients. Prevalence and Severity.”

• Title: Depression in orthopaedic trauma patients. Prevalence and severity
• Problem: Emotional distress, particularly depression, is known to be associated with physical injury and disability. However, the specific relationship between the severity of injury and the degree of depression, as well as the impact of physical function on depression, is not well understood.
• Focus: This study aims to clarify the prevalence and severity of depression among orthopaedic trauma patients and to explore the relationship between depression and various injury-specific factors.
• Study/Data Population: The study included 161 patients presenting to orthopaedic trauma services. Self-reported outcome measures and injury-specific data were collected.
• Parameters Measured:
  • Beck Depression Inventory (BDI)
  • Short Musculoskeletal Function Assessment (SMFA)
  • Physical Function-10 (PF-10) subset of the Short Form-36 (SF-36)
  • Injury-specific factors including AO Fracture Classification, Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and Gustilo and Anderson grade of open fractures.
• Key Results:
  • 55% of patients had minimal depression, 28% had moderate depression, 13% had moderate-to-severe depression, and 3.7% had severe depression according to the BDI.
  • Removing the somatic elements of the BDI reduced the prevalence of moderate to severe depression to 26%.
  • SMFA scores were strongly negatively correlated with the BDI (r = -0.75; p < 0.001).
  • Only open fractures significantly impacted the presence of depression, with an odds ratio of 4.58 (95% CI, 1.57 to 12.35).
• Limitations: Does not fully explore other potential factors influencing depression or the potential impact of varying levels of disability not captured by the measures used.

Westenberg et al., “Does a Brief Mindfulness Exercise Improve Outcomes in Upper Extremity Patients?”

• Problem: Traditional pain management strategies in orthopaedic practices often overlook the emotional and psychological components of pain. Mindfulness-based interventions have shown promise in reducing psychological distress and pain, but they are typically resource-intensive and not feasible for busy clinical settings.
• Focus: This study investigates whether a brief, 60-second mindfulness-based video exercise can improve pain intensity, emotional distress, and state anxiety compared to an attention placebo control (a time-matched educational pamphlet). It also examines the feasibility and acceptability of implementing such an intervention in a busy orthopaedic practice.
• Study / Data Population:
  • Sample Size: 149 patients initially approached; 125 completed the study.
  • Inclusion Criteria: Patients presenting for new or follow-up appointments at orthopaedic hand and upper extremity outpatient surgical practices.
  • Duration: September 2016 to December 2016.
  • Demographics: Average age 37.2 years; 67% men; average education of 13.1 years; average income $43,000/year.
• Parameters measured:
  • Pain intensity (Numeric Rating Scale, NRS)
  • State anxiety (State Trait Anxiety Inventory, State Anxiety Subscale)
  • Emotional distress (Emotion Thermometers for anxiety, anger, and depression)
  • Acceptability (Client Satisfaction Questionnaire Scale-3)
  • Feasibility (refusal rate for participation)
• Key results:
  • Pain Intensity: Mindfulness-based video exercise group reported lower pain intensity (3.03 ± 0.12) compared to the control group (3.49 ± 0.12), with a significant mean difference of 0.46 (p = 0.008).
  • State Anxiety: Reduced in the mindfulness group (32.35 ± 0.59) versus control (35.29 ± 0.59), with a mean difference of 2.94 (p = 0.001).
  • Emotional Distress: Improvements in anxiety symptoms, depression, and anger were observed in the mindfulness group compared to the control.
  • Anxiety Symptoms: Mindfulness (1.49 ± 0.19) vs. control (2.10 ± 0.19), mean difference 0.61 (p = 0.024).
  • Depression: Mindfulness (1.03 ± 0.10) vs. control (1.47 ± 0.11), mean difference 0.44 (p = 0.004).
  • Anger: Mindfulness (0.76 ± 0.12) vs. control (1.36 ± 0.12), mean difference 0.60 (p = 0.001).
  • Feasibility: The intervention had a 0% dropout rate and was deemed feasible; acceptability scores were similar between groups (mindfulness: 20.70 ± 5.48; control: 20.52 ± 6.42).
• Limitations:
  • Improvements in pain intensity were below the minimal clinically important difference (MCID) of 1 point on the NRS.
  • Lack of information on the long-term effects and clinical significance of the observed improvements.
  • Limited generalizability due to the specific setting and patient population.
  • No assessment of cost-effectiveness or durability of the intervention over multiple sessions.

Soberg et al., “Physical and Mental Health 10 Years after Multiple Trauma.”

• Problem: The long-term physical and mental health outcomes of individuals who have sustained severe multiple injuries and the impact of various factors on these outcomes.
• Focus: To evaluate how demographic and injury-related factors, as well as functioning at 1 and 2 years post-injury, affect physical and mental health 10 years after the trauma.
• Study/Data Population: Prospective cohort study involving 58 participants who completed a 10-year follow-up (55.2% of the original cohort). Data were collected on demographic and injury severity characteristics, and assessments were conducted at 1, 2, 5, and 10 years post-injury. Outcome measures included the SF-36 Physical and Mental Component Summaries (PCS and MCS), Brief Approach/Avoidance Coping Questionnaire, and cognitive function scale (COG).
• Parameters Measured: SF-36 PCS and MCS scores; coping strategies; physical, cognitive, and social functioning; and bodily pain. Hierarchical multiple regression analyses were used to assess predictors of PCS and MCS scores.
• Key Results: The mean PCS score was 41.8 (SD 11.7), indicating reduced physical health compared to the general population. The mean MCS score was 48.8 (SD 10.7), which was comparable to the general population. Predictors of PCS included changes in coping, physical functioning, cognitive functioning at 1 year, and bodily pain at 2 years. Predictors of MCS included changes in coping, vitality, social functioning, and mental health. Adjusted R² values were 0.57 for PCS and 0.64 for MCS.
• Limitations: The study's sample size was relatively small, and the follow-up rate was 55.2%, which may affect the generalizability of the results. The study did not account for potential changes in coping strategies or social support over time beyond the measured intervals.

Grogan Moore et al., “Patient-Reported Outcome Measures and Patient Activation.”

• Problem: Patient-Reported Outcome Measures (PROMs) are increasingly used to assess outcomes in orthopedic trauma, but applying these measures to trauma patients presents unique challenges due to the heterogeneous nature of injuries and the timing of initial assessments. There is a need to understand how PROMs and patient activation influence orthopedic trauma care and recovery.
• Focus: Reviews the role of PROMs in orthopedic trauma, emphasizing the need for psychometrically sound and validated tools to capture patient function, mental state, and activation. It also discusses the implementation challenges and benefits of incorporating PROMs into trauma care.
• Study/Data Population: Based on literature and expert opinions regarding PROMs and patient activation in trauma care. It cites examples and data from various studies and trauma registries.
• Parameters Measured: Covers general and condition-specific PROMs, mental health screenings, substance use assessments, and patient activation measures. It discusses their reliability, validity, and responsiveness in trauma settings.
• Key Results:
  • Function Measurement: PROMs should focus on functional outcomes as perceived by the patient, using both general and condition-specific measures.
  • Mental Health Screening: Mental health screens are crucial due to the high prevalence of conditions like depression and PTSD among trauma patients.
  • Substance Use Screening: Effective screening for substance abuse is important for managing trauma recovery and preventing complications.
  • Patient Activation: Higher patient activation levels correlate with better engagement in recovery and adherence to treatment.
• Limitations:
  • Implementation Challenges: The integration of PROMs into clinical practice can be hampered by costs, time constraints, and variability in practice settings.
  • Baseline Measurement Issues: Establishing baseline scores for trauma patients is difficult due to the lack of pre-injury data and potential recall bias.

Castillo et al., “Improving Outcomes at Level I Trauma Centers.”

• Background: “The Trauma Survivors Network (TSN), a program developed to help patients and families manage the psychosocial impact of their injuries, combines information access, self-management training, peer support, and online social networking. The purpose of this study was to evaluate the effectiveness of the TSN in improving patient reported outcomes among orthopedic trauma patients at a Level I trauma center.”
• Problem: Assess the impact of the TSN program on patient-reported outcomes, including depression, self-efficacy, and physical and mental health, at a large trauma center.
• Focus: Examine the effectiveness of the TSN program using a pretest-posttest lagged-control design and analyze usage and satisfaction with TSN resources.
• Study/Data Population: Patients admitted to the trauma center during control and treatment periods. Inclusion criteria: Trauma patients admitted during the study period. Exclusion criteria: Not explicitly stated.
• Parameters Measured
  • Baseline demographics: Age, sex, race, education, insurance status, ISS, GCS, self-efficacy, social support.
  • Outcome measures at 6 months: Depression (PHQ-9), self-efficacy, patient activation, physical health status, mental health status, anxiety.
  • TSN resource usage and satisfaction.
• Key Results
  • Depression: Treatment group had 54% lower odds of depression (PHQ-9 ≥ 10) compared to control (p = 0.020). After adjusting for covariates, the difference remained marginally significant (49% lower odds, p = 0.05).
  • Self-efficacy, patient activation, physical and mental health status, and anxiety: No significant differences between treatment and control groups (p > 0.10).
  • TSN resource usage: Low overall (3%-27% usage), with 47% of participants using at least one resource. Satisfaction with resources was generally high (40%-79% rating ≥ 7/10).
  • No significant differences in outcomes based on specific TSN component usage.
• Limitations
  • Non-randomized design due to logistical constraints.
  • Potential exposure of control group to TSN activities.
  • Sample size limitations and modest follow-up rates.
  • Low program participation rates.
• Conclusions: The TSN program shows potential benefits, particularly in reducing depression among trauma survivors. However, low participation rates highlight the need to understand barriers to program use and strategies to increase adoption. Further research and program enhancements are necessary to improve effectiveness and assess broader impacts.

Bhakta et al., “An Investigation in the Use of Propranolol as a Secondary Prevention of Post-Traumatic Stress Disorder in Patients Sustaining Orthopaedic Trauma.”

• Title: An Investigation in the Use of Propranolol as a Secondary Prevention of Post-Traumatic Stress Disorder in Patients Sustaining Orthopaedic Trauma
• Problem: PTSD is a complex psychological disorder with significant implications for patients sustaining orthopedic trauma. Current management largely focuses on tertiary prevention, often with limited benefit. There is a need to explore secondary prevention strategies.
• Focus: The use of propranolol as a potential approach for secondary prevention of PTSD in patients with orthopedic trauma.
• Study/Data Population: Patients sustaining orthopedic trauma, particularly those at high risk for developing PTSD. Relevant studies include both pediatric and adult populations with varied dosing regimens of propranolol.
• Parameters Measured:
  • Incidence of PTSD following orthopedic trauma
  • Psychological and physical function post-trauma
  • Return to work rates
  • Pain levels and overall recovery
  • Propranolol dosages and timing of administration
• Key Results:
  • PTSD and Orthopedic Trauma:
    • 20%-51% incidence of PTSD after orthopedic trauma.
    • Risk factors include motor vehicle accidents, multiple long bone fractures, lower extremity fractures, alcohol and drug abuse, low socioeconomic status, female gender, and younger age.
  • Propranolol and PTSD Prevention:
    • Propranolol reduces PTSD development by inhibiting memory consolidation of traumatic events.
    • Studies show a decrease in PTSD symptoms and physiological reactivity with propranolol use.
    • Pediatric dosing: 2.5 mg/kg (max 40 mg BID) initiated within 12 hours.
    • Adult dosing: 40 mg 4 times daily for 10 days, with tapering, or 30 mg 3 times daily for 7 days, with tapering.
  • Psychological and Physical Outcomes:
    • Improved psychological outcomes and quality of life with propranolol.
    • Reduced pain, improved function, and better return to work rates in trauma patients.
    • High association of PTSD with poor recovery and mental distress.
• Limitations:
  • Limited literature and standardized protocols for propranolol use in orthopedic trauma patients.
  • Variability in dosing regimens and timing of administration.
  • Need for further research to establish safety and efficacy.
  • Constraints on generalizability due to selected study designs and populations.
• Conclusion: Given the significant impact of PTSD on recovery from orthopedic trauma, propranolol shows promise as a secondary prevention strategy. Early mental health screening and prompt intervention are crucial. Further research is needed to validate propranolol's efficacy and safety. Practitioners should consider propranolol cautiously, avoiding its use in patients with contraindications such as asthma, heart block, hypovolemia, or hypoglycemia. Regular mental health assessments and referrals should be integrated into orthopedic care for high-risk patients.

Sheppard et al., “Effects of Marijuana Use in Patients with Orthopaedic Trauma.”

• Title: Effects of Marijuana Use in Patients with Orthopaedic Trauma
• Problem: To evaluate the impact of marijuana use on patients with orthopedic trauma.
• Focus: The study reviews the effects of marijuana use on traumatic brain injury (TBI), bone healing, bone mineral density (BMD), venous thromboembolism (VTE), and posttraumatic stress disorder (PTSD) in orthopedic trauma patients.
• Study/Data Population (including inclusion criteria):
  • Population: Patients with orthopedic trauma
  • Inclusion criteria: Patients with orthopedic trauma who use or have recently used marijuana or marijuana-based products.
    • “In pre-study screening, a diagnosis of PTSD was endorsed for 17.9% of these patients”
  • Exclusion criteria: Not specified.
• Parameters Measured:
  • Effects of marijuana on TBI
  • Effects of marijuana on bone healing
  • Effects of marijuana on BMD
• Key Results:
  • Endocannabinoid System and Bone Health: CB1 and CB2 receptors play protective roles in preventing age-related bone loss. CB2- knockout mice exhibit accelerated trabecular bone loss and a phenotype similar to postmenopausal osteoporosis.
  • Exogenous Cannabinoids: CBD enhances fracture healing in rodents, inhibits osteoclast function, and improves biomechanical properties of bones. THC's effects are mixed, with potential cytotoxicity and reduced MSC osteogenic differentiation.
  • Marijuana Smoke: Inhalation reduces bone area and bone-to-implant contact in cancellous bone of rats, though findings are complicated by high mortality in the smoke group.
  • TKA Outcomes: Marijuana users had an increased overall risk of revision TKA due to infection but a lower risk of periprosthetic fracture, implant failure, mechanical loosening, and osteolysis.
  • Bone Mineral Density: Heavy marijuana use is associated with lower BMD and higher fracture risk, though some studies found no association.
  • Venous Thromboembolism: Chronic marijuana use is linked to increased risk of DVT and PE in trauma patients, with cannabinoid receptors on platelets and vascular endothelium potentially playing a role.
  • PTSD: Low endocannabinoid tone contributes to PTSD symptoms. Cannabinoids may help mitigate these symptoms, but chronic use may lead to downregulation of cannabinoid receptors and increased PTSD susceptibility.
    • “It was found that cannabinoids can prevent depression-like symptoms in a rat model”
• Limitations:
  • Many studies rely on rodent models, limiting direct applicability to humans.
  • Human studies often depend on self-reported marijuana use, which may be inaccurate.
  • Confounding factors such as concurrent drug use and lifestyle differences complicate results.
  • Variability in marijuana strains and cannabinoid concentrations further limit standardization.
• Conclusion: The endocannabinoid system significantly impacts bone health and healing, with cannabinoids like CBD showing promise in enhancing fracture healing. THC's effects are more complex and may impede bone healing. Marijuana use is associated with mixed outcomes in orthopaedic trauma patients, including increased infection risk post-TKA and higher VTE risk. The role of cannabinoids in PTSD treatment shows potential but requires further research to fully understand their benefits and risks.