Perioperative Interdisciplinary Intervention Contributes to Improved Outcomes of Adolescents Treated With Hip Preservation Surgery.

BACKGROUND: Adolescent hip preservation surgery (HPS) candidates typically present with chronic pain, which can negatively affect psychological function and surgical outcomes. A previous study demonstrated high rates of psychological symptoms and maladaptive behaviors in this population. This study quantified psychological and functional improvements in these patients from preoperative presentation to postoperative follow-up. An integrated interdisciplinary approach is also described. METHODS: A total of 67 patients undergoing HPS were evaluated preoperatively and postoperatively at 1 year by staff psychologists. Perioperative psychological intervention consisted of education, counseling, and administration of self-report measures. Self-report measure scores were compared preoperatively and postoperatively, grouped by orthopaedic diagnoses. Frequency analysis, correlational analysis, and analysis of variance were conducted. RESULTS: Psychological function improved significantly at follow-up: decreased emotional symptomatology (46.1 to 43.6, P=0.013), anxiety (49.6 to 45.8, P<0.001), school problems (46.6 to 44.7, P=0.035), internalizing problems (46.3 to 44.1, P=0.015), social stress (44.5 to 42.3, P=0.024), sense of inadequacy (49.0 to 46.0, P=0.004), and increased self-concept (51.1 to 54.1, P=0.003). Resiliency factors also significantly improved: increased mastery (50.3 to 52.9, P=0.001) and resourcefulness (49.7 to 52.0, P=0.046), decreased emotional reactivity (46.3 to 42.9, P=0.001), and vulnerability (47.7 to 44.7, P=0.011). Physical function and return to activity also significantly improved (University of California-Los Angeles: 7.1 to 8.7, P=0.017; modified Harris Hip Score: 67.3 to 83.8, P<0.001). Return to activity positively correlated with optimism and self-efficacy (P=0.041). Femoroacetabular impingement and hip dysplasia patients consistently reported feeling less depressed (P=0.036), having fewer somatic complaints (P=0.023), fewer internalized problems (P=0.037), and exhibiting fewer atypical behaviors (P=0.036) at follow-up. Slipped capital femoral epiphysis patients did not demonstrate improvements in psychological functioning postoperatively. CONCLUSIONS: Perioperative psychological education and counseling, in combination with HPS, improved postoperative psychological and physical function. Patients reported reduced anxiety, school problems, and social stress, with marked increase in resilience. Increased mobility and return to activity significantly correlated with improved optimism and self-efficacy. LEVEL OF EVIDENCE: Level II-therapeutic studies-investigating the results of treatment.

Clinical Implications of Psychosocial Factors on Pediatric External Fixation Treatment and Recommendations.

BACKGROUND: Pediatric limb reconstruction using circular external fixation is a prolonged treatment that interrupts patients' daily function. Patient personality characteristics and expectations may interfere with planned treatment, making complicated medical procedures more challenging. The aims of this study are to identify factors impacting treatment outcome and recommendations for preoperative evaluation and planning. QUESTIONS/PURPOSES: (1) Are there group differences between patients with and without a preexisting mental health condition(s) in terms of unplanned reoperations? (2) Does the number of surgical procedures before current external fixator placement correlate with the number of unplanned readmissions, unplanned reoperations, and days spent in circular external fixation? (3) Are there group differences between single- compared with two-parent households in terms of inpatient narcotic doses, length of inpatient stay, number of unplanned readmissions, length of readmission(s), and/or unplanned outpatient clinic visits? (4) Does patient age at the time of surgery have an impact on treatment duration, postoperative complications, and treatment outcome? METHODS: This is a retrospective chart review of pediatric patients who underwent limb reconstruction between 2008 and 2012. Patients with limb length discrepancy > 4 cm or severe angular deformity and who agreed to intervention were treated with circular external fixation. Sixty-seven patients were included; 16 patients were excluded. Statistical analyses included Pearson r correlation and t-test. RESULTS: Patients who reported preexisting mental health diagnosis (13%) had more unplanned reoperations than patients who did not (no mental health diagnosis; 87%) (mental health diagnosis 3.4 ± 10.3 versus no mental health diagnosis 0.2 ± 0.5 reoperation[s], p = 0.022). Number of previous surgical procedures correlated with number of unplanned reoperations (r = 0.448, p < 0.001), number of unplanned readmissions (r = 0.375, p < 0.001), and number of days in an apparatus (r = 0.275, p = 0.018). Compared with patients from two-parent households, patients from single-parent households received a greater number of inpatient narcotic doses (single-parent 129 ± 118 versus two-parent 73 ± 109 doses, p = 0.039), longer length of inpatient stay (single-parent 73 ± 63 versus two-parent 40 ± 65 days, p = 0.036), more unplanned readmissions (single-parent 0.4 ± 0.1 versus two-parent 0.2 ± 0.2 readmission, p = 0.024), longer hospitalization when readmitted (single-parent 5 ± 11 versus two-parent 1 ± 3 day(s), p = 0.025), and fewer unplanned outpatient visits (single-parent 0.2 ± 0.8 versus two-parent 0.9 ± 1.1 visit, p = 0.005). Apparatus applications with successful outcome had higher average age than those with poor outcome (successful outcome 16 ± 3 versus poor outcome 13 ± 4 years old, p = 0.011). Age at time of apparatus application correlated with number of prescribed antibiotics (r = 0.245, p = 0.036) and number of days in an apparatus (r = 0.233, p = 0.047). CONCLUSIONS: As a result of the inherent challenges of limb reconstruction, surgical candidates should be preoperatively assessed and mitigating psychosocial factors managed to maximize successful treatment outcome. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Preoperative psychological findings in adolescents undergoing hip preservation surgery.

BACKGROUND: Chronic pain is associated with increased anxiety, depression, and maladaptive behaviors, especially in adolescents. We hypothesized that adolescents with chronic hip pain selected for hip preservation surgery (HPS) would demonstrate increased anxiety and depression compared with same-age peers. We designed a study to assess the psychological state of adolescents before HPS. METHODS: We prospectively evaluated 58 patients (23 males, 35 females), average age 16.5 years (range, 11 to 19 y) before HPS. Their diagnoses included: femoroacetabular impingement (n=25), acetabular dysplasia (16), Perthes disease (11), and slipped capital femoral epiphysis (6). Psychological questionnaires included patient-completed and parent-completed Behavioral Assessment System for Children, Second Edition (BASC-2), Beck Youth Inventory, Second Edition (BYI-II), and Resiliency Scales. Self-reported functional questionnaires included the modified Harris hip score (mHHS, max 100) and the UCLA activity score. Psychological scores were compared between diagnoses, procedures performed, and self-reported functional scores with a Student t test and ANOVA. RESULTS: All patients reported pain, 52 (90%) reported pain >6 months with 28 (54%) >1 year. A total of 44 patients (76%) reported moderate or severe pain. All reported decreased function: average UCLA 7.25 (range, 2 to 10), average HHS 65.5 (range, 27.5 to 97.9). At presentation, 10 patients (17.2%) were receiving psychological intervention and 30% had a family history of mental illness. On the basis of the BYI-II scales, 10% and 31% of patients reported at-risk or clinically significant symptoms of anxiety and depression, respectively. Similarly, using the BASC-2 measure, 28% and 14% reported at-risk or clinically significant anxiety and depression, respectively. Resiliency scales demonstrated that 21% to 36% of patients report maladaptive behavior. There were no significant correlations between any psychological score and diagnosis, procedure, or preoperative functional score. CONCLUSIONS: Preoperative evaluation identified patients who reported at-risk or clinically significant symptoms of anxiety and/or depression, with up to one third of patients reporting maladaptive behavior that may significantly influence their postoperative outcomes. Preoperative psychological evaluation, with appropriate intervention and follow-up, if needed, should be considered before surgery selection as mental health conditions may be undiagnosed and will likely influence functional outcomes.