| Objective: Emotional distress and chronic pain usually occur together.Individuals with chronic pain are twice as likely to suffer from anxiety or depression disorders.About thirty percent of chronic foot and ankle disease patients had anxiety or depression,which causes emotional distress that significantly affects patient health care cost,work productivity and functioning.Previous research has demonstrated the relevance of depression and anxiety on clinical outcomes in many surgical disciplines.Mood disorder patients more likely to require additional narcotic postoperatively,have a high risk of continued pain more than 90 days after surgery,and high visual analogue scale for pain scores over one year after surgery compared to those without mood disorders.In addition,studies have shown that greater emotional distress can have a negative role on hip and knee arthroplasty as well as spinal surgery and rotator cuff outcomes.Recent studies indicate that preoperative depression and anxiety symptoms have a negative impact on surgical outcomes and patient satisfaction following hallux valgus surgery,and total ankle arthroplasty.However,anxiety and depression are important factors to consider and address because their presence before surgery can predict poor postoperative outcomes including the severity of postoperative pain,persistent postoperative pain,and increased consumption of narcotic drugs.Thus,the aims of the present study was to estimate the prevalence of depression and anxiety symptoms among Chronic ankle instability(CAI)patients.The secondary aims were to examine the effect of these symptoms on preoperative sleep quality,pain and daily functions,and study the association between patients’ characteristics and preoperative symptoms of depression and anxiety.Finally,to explore whether improvement in depressive and anxiety symptoms could be due to improved outcomes at 3,6,12,and 24 months after surgery.Methods: We conducted a retrospective cohort study for patients who underwent arthroscopic repair of Anterior Talofibular Ligament(ATFL)for chronic ankle instability between Jan 2016 and Oct 2018,the data of 120 patients(53 males and 67 females;61left ankles,59 right ankles).The mean patient’s age at the time of surgery was 35.3±9.8years.The mean Identification of Functional Ankle Instability questionnaire(Id FAI)score was 24.7±4.7 points.72.5% of these injuries were caused by sport related injury,and 27.5% of injuries were caused by accident or work related-injury,and the mean duration of symptoms was 27.0±8.8 months.Repeated ankle sprains,chronic ankle instability,and chronic pain(persistent pain)after a traumatic experience were the indication for surgery.The hospital Anxiety and Depression Scale(HADS),Zung Self-Rating Depression Scale(SDS),Zung Self-Rating Anxiety Scale(SAS)were used to evaluate anxiety and depression.Pittsburgh Sleep Quality Index(PSQI)was used to evaluate sleep disturbance.American Orthopaedic Foot and Ankle Society(AOFAS)ankle-hindfoot Scale was used to evaluate objective and functional outcomes.Karlsson Ankle Function Scale(KAFS)was used to evaluate ankle functions.The visual analog scale(VAS)was used to compare the changes in the pain outcomes.The 10-item SF-36 physical functioning and 2-item SF-36 bodily pain were used to evaluate the pain and quality of life of the patients.The Self-Administered Foot Evaluation Questionnaire(SAFE-Q)scale was used to evaluate pain and function.At the final follow-up visit,patients were asked to rate their satisfaction on a 5-point Likert scale.All variables were measured at baseline,3,6,12 and 24 months postoperatively.The subjects with a HADS-D Scale score of ≥ 8 and SDS score of ≥ 50 were classified in to the depressive group;those with a HADS-A scale score <8 and SDS score< 50 were classified into the non-depressive group.The same for anxiety;the subjects with a HADS-A Scale score of ≥ 8 and SAS score of ≥50 were classified in to the anxiety group,and those with a HADS-A scale score <8 and SAS score < 50 were classified into the non-anxiety group.The Wilcoxon matched-pairs signed rank test was used to assess the change in anxiety,depression,sleep disturbance,AOFAS,KAFS,VAS,SF-36,and SAFE-Q scores.Logistic regression model was used to evaluate characteristics of patients with preoperative anxiety or depression symptoms,and the effect of anxiety/ depression change on clinical outcomes.P-value < 0.05 was considered as statistically significant.Results: In this study,120 patients(53 men and 67 women)underwent CAI surgery were included and followed up for at least 24 months postoperatively.There were no statistically significant differences in baseline characteristics between patients with or without anxiety and depression,including age,gender,BMI,and follow-up period.Among the 120 patients,45(37.5%)had depression,defined as SDS depression score of50 or more.Of these,18(40%),14(31.1%),5(11.1%),and 4(8.9%)patients saw statistically significant improvement in their depression during 3,6,12,and 24 months,respectively,postoperatively,according to SDS score(P <0.001).Regarding anxiety symptoms,as indicated by the SAS score,35(29.2%)of patients scored 50 or more,and 17(48.5%),5(14.3%),6(17.2%),and 5(14.3%)of these patients saw statistically significant improvement in their anxiety during 3,6,12,and 24 months,respectively,postoperatively according to SAS score(P <0.001).At baseline,there was no statistically significant difference between depression status by HADS-D score and depression status by SDS score,and anxiety status by HADS-A score,anxiety status by SAS score.Regarding the second aim,preoperative,3 months,and 6 months after surgery PSQI scores,AOFAS scores,KAFS scores,VAS,SF-36 bodily pain and SF-36 physical functioning scores,and SAFE-Q subscale scores were significantly worse in patients with depression or anxiety when compared to those without it,whereas no statistically significant difference was observed at 12,and 24 months after surgery.At the final follow-up visit,there was no statistically significant difference in satisfaction scores between patients who had depression or anxiety versus those who had no depression or anxiety.Regarding the associations of the patient characteristics with preoperative depression and anxiety symptoms,duration of symptoms was associated with preoperative depression(P< 0.05),but not with preoperative anxiety.Reduction in depression and anxiety symptoms from preoperative to 24 months after surgery was significantly associated with improvements in sleep quality,objective and functional activities,pain severity,physical and social function,general health and well-being from preoperative to 24 months after surgery outcomes based on PSQ,AOFAS,VAS,SF-36 bodily pain and physical function,and SAFE-Q subscale scores(P< 0.05).Furthermore,improvement in patients reported outcomes based on PSQ,AOFAS,KAFS,VAS,SF-36 bodily pain and physical function,and SAFE-Q subscale scores was associated with depression and anxiety improvement at 24 months after surgery(P <0.05).Conclusion: Our study shows that the prevalence of depression and anxiety were 37.5%and 29.2% respectively,in patients with CAI.The presence of preoperative depression and anxiety symptoms were significantly associated with poor sleep quality,reduced physical and social functioning,and worse pain compared to those without depression or anxiety symptoms.Clinical considerations of such factors are essential before arthroscopic ATFL repair for CAI to tailor the preoperative depression/anxiety management protocol.Treatment of preoperative depression and anxiety symptoms can contribute to better postoperative outcomes following CAI surgery.Thus,postsurgical positive change in depression and anxiety symptoms not only results in reduced pain,but also an increase in overall functioning and patient satisfaction. |
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