One in three patients having shoulder arthroplasty had depression or anxiety - what effect did this have on outcome and what should we do about it?

Anxiety and depression are the most commonly diagnosed psychiatric disorders in the United States, with a lifetime prevalence of about 29% and 17%, respectively. Thus, it is not surprising that a substantial percentage of patients considering shoulder arthroplasty (TSA) carry these diagnosis. Several questions arise:
(1) what are the effects of these mental health conditions on the outcomes of shoulder arthroplasty?
(2) can the adverse effects of depression and/or anxiety be modified (i.e are these risk factors modifiable)?
(3) how should the presence of depression and/or anxiety affect the decision to proceed with shoulder arthroplasty, recognizing the increased risk for suboptimal results and adverse outcomes?

The authors of the Impact of Mental Health on Outcomes After Total Shoulder Arthroplasty sought to examine the correlation between the preoperative diagnoses of anxiety and depression and their association with postoperative outcomes for TSA. A secondary goal was to determine whether patients on medication for their mental health diagnosis fared better than those not receiving medication.

In the authors' practice over one-third (37%: 218 patients (114 rTSA and 95 aTSA)) had anxiety and/or depression while 378 (153 rTSA and 217 aTSA) had no such history.

For patients having reverse total shoulder arthroplasty, the preoperative patient and shoulder characteristics of those without and with depression and/or anxiety were essentially the same. However, the postoperative comfort, function, satisfaction and adverse event rate were significantly worse for those with depression and/or anxiety.

For patients having anatomic total shoulder arthroplasty, the results were similar, but somewhat less striking.

Patients on medications for treatment of depression and/or anxiety did not have better postoperative outcomes or satisfaction rates compared to those who had depression and/or anxiety but who not on medication. However, it is not known (1) whether the patients on medication had more severe depression and/or anxiety than those not on medication and (2) whether the patients on medication would have had even worse outcomes had they not been medicated.

Poorer mental health correlated with worse postoperative functional outcomes, worse patient satisfaction, and higher rates of adverse events.

Comment: The high prevalence of anxiety/depression is striking. As emphasized in this study as well as in Shoulder arthritis: the relationship of function, depression and anxiety and Total shoulder - one in seven patients have depression; what difference does that make? poor mental health is associated with poorer outcomes following shoulder arthroplasty.

The authors suggest that preoperative identification of these mental health disorders may allow for treatment and "an opportunity to intervene and mitigate any deleterious effect". However it is not clear whether medical management of anxiety/depression mitigates their adverse effects on arthroplasty outcomes. To figure this out, it would be necessary to randomize patients with anxiety/depression to treatment and non-treatment groups prior to arthroplasty.

It is also not clear how surgeons should consider the patient with suboptimal mental health. Should they counsel these patients that they are more likely to get a poor result? Or should they consider not offering surgery to these patients to avoid the ramifications of bad outcomes for the patient and for the surgeons themselves?

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

What determines the symptoms of shoulder arthritis?

Associations of preoperative patient mental health status, sociodemographic and clinical characteristics with preoperative pain, function and satisfaction in patients undergoing primary shoulder arthroplasty

These authors investigated the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in 788 patients undergoing primary shoulder arthroplasty. 

Worse mental health status as assessed by VR-12 MCS was associated with lower Penn Scores. Patients with intact or small/medium rotator cuff tears had more pain than patients with a large/massive superior-posterior rotator cuff tear. Female sex, fewer years of education and preoperative opioid use were associated with lower preoperative Penn Scores.

Glenoid bone loss was not associated with preoperative Penn Scores.

Comment: This article serves to remind us that the symptoms manifested by patients with shoulder arthritis are less related to characteristics of the shoulder (extent of bony pathology) and more related to characteristics of the patient (mental health status, sex, education, opined use).

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Total shoulder arthroplasty - the effect of mental health

The Influence of Mental Health on Outcomes Following Total Shoulder Arthroplasty

Anxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). These authors conducted an observational cohort study including 143 shoulders in 135 subjects undergoing total shoulder arthroplasty for glenohumeral osteoarthritis. The types of implants used and the methods used for addressing non-concentric glenoids are not specified.

Radiographs were reviewed for all 143 shoulders included. Advanced imaging was available for 60 shoulders. On initial review, there was 68.5% (99/143 shoulders) agreement on modified Walch glenoid morphology according to each subtype. Preoperative glenoid pathology was classed as either concentric wear (glenoid types A1 or A2) or eccentric wear (glenoid types B1, B2, B3, C, or D). When grouped as concentric vs. eccentric glenoids, initial review agreement improved to 86% (123/143 shoulders). 65 shoulders (45.5%) were graded as concentric and 78 shoulders (54.5%) were graded as eccentric following consensus analysis. Final Walch subtype classification included 26 shoulders graded as A1, 39 as A2, 8 as B1, 45 as B2, 23 as B3, and 2 as C. There were no glenoids graded as D.

Patients with anxiety and depression reported similar improvements in pain and function following TSA similar to those without depression or anxiety.

Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=.035) and were more likely to regret undergoing surgery.

The ASES scores were somewhat higher for the patients with non-concentric glenoid.

Comment: This article demonstrates an association between the degree of anxiety and depression with the preoperative and postoperative ASES scores. It does not suggest how this information might be used to improve the care of patients having shoulder arthroplasty. For example, how should patients undergoing TSA be screened for anxiety/depression? Should the presence of anxiety/depression influence the indications for surgery? Might the management of anxiety/depression preoperatively improve the outcomes of total shoulder arthroplasty?

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Rotator cuff tears - how does mental health relate to pain and function?

Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears.

These authors studied 169 patients with full-thickness rotator cuff tears using the Short Form-36, visual analog scales for shoulder pain and function, the Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons (ASES) instrument at the time of diagnosis. These results were correlated with the MRI interpretation of the number of tendons involved, tear size, tendon retraction, and tear surface area as well as sex, body mass index, number of medical comorbidities, smoking status, and Workers' Compensation status.

The SF-36 mental component summery (MCS) had the strongest correlation with the visual analog scale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score. 

Tear severity by MRI only correlated with the visual analog scale for shoulder function. Tear severity did not correlate with other scores in bivariate correlations. In all multivariate models, the SF-36 MCS had the strongest association with the visual analog scale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score.

The authors conclude that patient mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears.

Comment: Once again we see that the symptoms experienced by patients rotator cuff tears are related to factors other than the severity of the rotator cuff pathology. The importance of the different elements of the SF36 on shoulder comfort and function is shown by prior studies as well. Three relevant abstracts are provided here. Again we emphasize the importance of the 4Ps (patient, problem, physician, procedure): the characteristics of the patient may be more important than the characteristics of the shoulder problem. These studies help us realize that patients with poor mental health are likely to have poorer shoulder comfort and function both before and after treatment.

Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease.

Although most patients are improved after shoulder arthroplasty, the degree of improvement is variable. The factors contributing to this variability are not well understood. In particular, little information is available regarding the preoperative characteristics of the patient that may influence the quality of the result. This study correlated patient demographics, preoperative health status, and preoperative shoulder function with 3 outcome metrics: comfort, physical role function, and shoulder-specific function. One hundred thirty-four shoulders having total shoulder arthroplasty for degenerative glenohumeral joint disease had an average follow-up of 3.4 +/- 1.8 years. The SF-36 Comfort score improved from 39 to 61 (P < .0001). The SF-36 Physical Role Function score improved from 30 to 52 (P < .0001). The average number of Simple Shoulder Test functions performable (out of 12) improved from 4 to 9 (P < .0001). The strongest correlates with postoperative comfort included preoperative physical function (P < .0001), general health (P < .0001), and social function (P < .001). The strongest correlates with postoperative physical role function included preoperative physical function (P < .0001) and general health (P < .001). The strongest correlates with postoperative shoulder function included male gender (P < .0001), and preoperative physical function (P < .0001), social function (P < .0001), mental health (P < .0001) and shoulder function (P < .0001). These data indicate that the overall well-being of the patient before surgery is strongly correlated with the quality of the outcome from total shoulder arthroplasty for degenerative glenohumeral joint disease.

A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status.

Rotator cuff tears are among the most common conditions of the shoulder. One of the major difficulties in studying patients with rotator cuff tears is that the clinical expression of these tears varies widely and different practices may have substantially different patient populations. The goals of the present prospective multipractice study were to use patient self-assessment questionnaires (1) to identify some of the characteristics of patients with rotator cuff tears, other than the size of the cuff tear, that are correlated with shoulder function, and (2) to determine whether there are significant differences in these characteristics among patients from the practices of different surgeons.

Ten surgeons enrolled a total of 333 patients with a full-thickness tear of the supraspinatus tendon into this prospective study. Each patient completed self-assessment questionnaires that included items regarding demographic characteristics, prior treatment, medical and social comorbidities, general health status, and shoulder function.

As expected, patients who had an infraspinatus tendon tear as well as a supraspinatus tendon tear had significantly worse ability to use the arm overhead compared with those who had a supraspinatus tear alone (p < 0.005). However, shoulder function and health status were correlated with patient characteristics other than the size of the rotator cuff tear. The number of shoulder functions that were performable was correlated with the subscales of the Short Form-36 and was inversely associated with medical and social comorbidities. The patients from the ten different surgeon practices showed significant differences in almost every parameter, including age, gender, method of tear documentation, tear size, prior treatment, medical and social comorbidities, general health status, and shoulder function.

Clinical studies on the natural history of rotator cuff tears and the effectiveness of treatment must control for a wide range of variables, many of which do not pertain directly to the shoulder. Patients from the practices of different surgeons cannot be assumed to be similar with respect to these variables. Patient self-assessment questionnaires appear to offer a practical method of uniform assessment across different practices.


The correlation of comorbidity with function of the shoulder and health status of patients who have glenohumeral degenerative joint disease.

We studied the effect of comorbidities on function of the shoulder and health status in a group of eighty-five consecutive patients who had glenohumeral degenerative joint disease of sufficient severity to meet one surgeon's criteria for the performance of shoulder arthroplasty. A questionnaire was used to identify the comorbidities, such as other diseases, social factors, or a work-related injury, for each patient. The number of functions on the Simple Shoulder Test that the patient could perform had a significant negative correlation with the number of comorbidities (r = -0.32, intercept = 4.6 per cent, slope = -0.6, and p = 0.0031). Each parameter on the Short Form-36 (except for physical role function) had a significant negative correlation with the number of comorbidities (p < 0.05). This negative relationship was strongest for general health perception (r = -0.42) and vitality (r = -0.35). We concluded that the number of comorbidities has a quantitative effect on function of the shoulder. In the evaluation of the functional status of patients and the effectiveness of treatment, the effects of comorbidity must be controlled. The results of the present study demonstrate that the scores on the Short Form-36 are quantitatively related to the number of comorbidities. The six parameters that are unrelated to function of the shoulder (physical function, social function, emotional role function, mental health, vitality, and general health perception) may provide a practical way to integrate the effects of all potential comorbidities on individual patients. Future clinical research will be strengthened by efforts to measure the impact of comorbidities and by strategies to control for their effects.

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