Summary
ACL re-injury negatively impacts mental health as nearly 1 in 3 demonstrate meaningful worsening of PROMIS Mental Health scores and roughly 1 in 6 are diagnosed with depression or anxiety after re-injury.
Abstract
Background
It has been well established that a person’s preoperative mental health and emotional wellbeing can impact orthopaedic postoperative outcomes; however, the impact of a poor surgical outcome on mental health has not been evaluated. The purposes of this study were to quantify the incidence of worsening mental health after anterior cruciate ligament (ACL) re-injury and to determine if patient and/or clinical factors are predictive of worsening mental health after re-injury.
Methods
As part of this IRB-approved retrospective study, we used Current Procedural Terminology (CPT) code 29888 to identify individuals since 2015 who had undergone a minimum of two ACL reconstructions involving the same knee on separate dates. PROMIS Mental Health Health scores were recorded prior to the index and revision surgical procedures. Age, sex, laterality, and the time between the index and revision ACL reconstruction procedures were recorded. Individuals were categorized as having worsening PROMIS Mental Health scores if scores decreased by > 5 points between the index and secondary ACL reconstructions. A logistic regression with forward variable selection was performed to determine if sex, age, time between surgical procedures, laterality, or preoperative PROMIS Mental Health or Physical Health scores were predictive of worsening PROMIS Mental Health scores after ACL re-injury. Additionally, ACL reconstruction patients ? 25yrs old were identified in the Truven Healthcare Marketscan database. We then identified patients with a diagnosis of depression or anxiety after primary ACL reconstruction and whether patients underwent subsequent secondary ACL reconstruction (either revision or contralateral procedures). A logistic regression was fit to assess the interaction between sex and either secondary ACL reconstruction on postoperative diagnosis of depression or anxiety.
Results
Of 75 patients with complete PROMIS and clinical data (39 females, 26 males; age=29.1±11.8 y), 23 (30.6%) demonstrated meaningful reductions in PROMIS Mental Health scores after re-injury. Sex (p=0.13), age (p=0.37), time between surgical procedures (p=0.84), laterality of second ACL injury (p=0.09), PROMIS Mental Health (p=0.55), and PROMIS Physical Health scores (p=0.55) were not predictive of worsening PROMIS Mental Health scores after ACL re-injury. From the insurance claims data, we identified 42,174 ACL patients. The incidence of subsequent depression or anxiety diagnosis was significantly greater for those that underwent a secondary ACL reconstruction than those that did not suffer an ACL re-injury (15.8% vs. 11.3%, OR=1.47, p<0.0001). Re-operation was an independent risk factor for postoperative depression/anxiety diagnosis.
Conclusions
The current results suggest a bidirectional relationship exists in which re-injury may negatively impact mental health. Of those suffering a secondary ACL injury, nearly 1 in 3 demonstrated meaningful worsening of PROMIS Mental Health scores and roughly 1 in 6 were diagnosed with depression or anxiety. Patient and clinical factors were not predictive of worsening mental health after re-injury which suggests the potential needs for continued monitoring of mental health throughout recovery and development and implementation of referral pathways for those with worsening mental health after surgery.