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Fig. 1 Adjusted PROMIS scores following surgery
Courtesy of David N. Bernstein, MD, MBA, MA

AAOS Now

Published 9/2/2021
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Terry Stanton

Study Probes Role of Depression in Recovery from Ankle Fracture

Those with no or low-level depressive symptoms have greater improvement

A study exploring the role of depression in functional and pain outcomes for patients treated for an isolated ankle fracture found that all patients have postoperative improvement, but those with no or low-level depressive symptoms improve to a greater extent.  

The study, presented Wednesday by David N. Bernstein, MD, MBA, MA, from the Department of Orthopaedics and Physical Performance at the University of Rochester Medical Center, sought to answer the following questions:

  • What is the recovery pattern, as measured by Patient-reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression scores, of patients undergoing operative management for ankle fractures?
  • What is the association between moderate or high levels of depressive symptoms (i.e., PROMIS Depression ≥60) and function and pain (i.e., PROMIS PF and PI) during patient recovery following surgery for ankle fractures?
  • Do different thresholds for depressive symptoms alter the association between depressive symptoms and function and pain (i.e., PROMIS PF and PI)?

“As healthcare continues to move toward rewarding value over quantity, we need to progress as a specialty to better understand how to optimize clinical outcomes per dollar spent across the entire cycle of care for a given condition,” Dr. Bernstein told AAOS Now Daily Edition, explaining the impetus for the study. “A key element of that goal is understanding what factors or characteristics may be associated with better or worse clinical outcomes. Mental health, especially depression, has been shown in many studies to be associated with clinical outcomes. However, it was unknown to what degree this association existed throughout the one-year recovery timeframe for patients with and without high levels of depressive symptoms who underwent surgical intervention for ankle fractures.”

The study involved 153 patients meeting inclusion criteria. Recovery progress was measured with the PROMIS PF, PI, and Depression instruments. After the researchers controlled for confounders, the regression analysis for all patients showed a reduction (i.e., improvement) in both PROMIS PI and Depression scores relative to preoperative ratings. Scores never returned to the same level of negative impact at one year postoperatively, the authors reported. The trend analysis of PROMIS PF scores showed a reduction relative to preoperative scores that rebounded to preoperative level or higher by three months postoperatively, on average.

When researchers analyzed the impact of depression on the recovery trajectory, they found that PROMIS PF scores for patients with no or mild depression rebounded to preoperative values between two months postoperatively, with scores 3.3 points lower on average, and three months postoperatively, with scores 4.7 points higher on average. The marginal effect of depression on physical function showed that PROMIS PF scores for patients with moderate/severe depression (defined as PROMIS Depression ≥60) rebounded to preoperative values between three months postoperatively, with scores 0.5 points lower on average (4.7–5.2), and four months postoperatively, with scores 2.3 points higher on average (7.5–5.2).

Asked about the key clinical takeaway for the study, Dr. Bernstein said that the results may improve the “ability to set clinical recovery/outcome expectations preoperatively, both for patients and for surgeons. Indeed, our study demonstrates the recovery pattern for patients who have ankle fractures operatively addressed overall, as well as by depressive symptom level.”

Although the study yielded no major unexpected findings or surprises, Dr. Bernstein commented, “Our results just reinforce the interplay between mental and physical health even in the setting of unexpected orthopaedic trauma.”

The findings also demonstrate the value of patient-reported outcome measures, or PROMs, in understanding patients’ feelings across a wide array of domains. “These instruments should be utilized commonly in clinical practice in our opinion and help provide remarkable insight,” Dr. Bernstein said. “Addressing depression is a much bigger challenge, and we think future work is needed to determine if clinical outcomes are improved with certain mental health interventions/resources pre-, peri-, or postoperatively.”

He said the findings point to a pressing need to assess “whether increased resource allocation pre-, peri-, or postoperatively or preoperative mental health optimization can improve clinical outcomes in patients with ankle fractures undergoing surgical intervention.”

He noted that the major limitation or “point of contention” of the study was its definition of high versus no or low depressive symptoms. “We utilized PROMs to do so, but other researchers could prefer to utilize a clinical diagnosis from a psychiatrist or the routine use of antidepressant medications, for example,” he explained. “Nonetheless, we feel the use of validated PROMs is an appropriate way to screen and assess patient mental health.” Additional limitations included the single-center design and the notable portion of patients with missing data.

Dr. Bernstein’s coauthors of “Operative Management of Ankle Fractures: Does the Presence of Depression Have an Impact on Patient-Reported Outcomes?” are Gabriel Anthony Ramirez, BS; Jeff R. Houck, PT, PhD; Adolph Samuel Flemister, MD; Irvin C. Oh, MD; John P. Ketz, MD; and Judith F. Baumhauer, MD, MPH.

Terry Stanton is the senior medical writer for AAOS Now. He can be reached at tstanton@aaos.org.