2.1 Database search

Two electronic databases, PubMed and OVID MEDLINE, were systematically searched. Search terms were a combination of these elements: (a) orthopaedics, (b) behavioral, (c) therapy, and (d) surgical. All keywords corresponding with the search elements were used as terms, title words, and abstract words in all databases. Reference lists of related reviews were then checked for useful references.

2.2 Literature inclusion

Studies in the English language and published between the years of 2005–2019 were considered for inclusion. Papers were then included if they could affirmatively answer the following questions: (a) Did the article include an orthopaedic population? (b) Did the article include data on mental health, psychosocial, or psychological profile of orthopaedic patients? (c) Did the article report outcomes in regard to mental health? (d) Did the article discuss ways of managing mental health in the patient population?

The title and abstract of all studies were screened; full-text articles were retrieved in cases of uncertainty (i.e., surgical population, therapy used). The following data from the included studies were then extracted: study type, orthopaedic focus area, if applicable, and outcomes. PRISMA guidelines were used to determine final eligibility of the papers included in this review.

Two reviewers (KR,CC) independently assessed risk of bias. Because no validated risk of bias assessment in the orthopaedic setting could be identified, a checklist was developed based on the principles of the Cochrane Risk of Bias Tool. The checklist contained six items and evaluated risk of bias in subject selection, reporting of outcomes, experimental design used, and discussion topic. The bias assessment was expressed as a percentage of the maximum score and risk of bias was considered low when the score was at or above 75%.

3.1 Literature search

The combination of “osteochondral allograft” with any of the other keywords used produced no relevant publications. The database search produced a total of 33 articles for review. The bibliographies of those articles were also reviewed, producing five additional relevant publications. This resulted in inclusion of 38 articles for full review, after which, eight met all criteria for inclusion in this systematic review (Fig. 1). Four studies were randomized controlled trials (RCTs), two were systematic reviews, and two were prospective cohort or case-controlled studies. Four (50%) of the studies used appropriate data collection durations of at least 6 months for prospective studies or 12-months recall for retrospective studies. Brief descriptions of the included studies are provided in Table 1.

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Fig. 1 Flowchart showing record review and study inclusion.

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3.2 Risk of bias assessment

The final results of the bias assessment are displayed in Table 2. Two articles received a score of 75% and were considered to have low risk of bias. Three studies received a score of 66%, indicating medium to low risk of bias, and two studies were scored at or below 50%, indicating moderate to high risk of bias.

4.1 Impact of behavioral health preoperatively on total joint arthroplasty

The systematic review of available data supported an association between lower overall function scores in orthopaedic patients who are psychologically distressed preoperatively as defined by their Axis I diagnosis (i.e., major/other depressive syndrome, somatization syndrome, panic syndrome, and anxiety syndrome). Howard et al.⁵ examined prevalence of Axis I diagnoses, and their effects on preoperative pain, disability, function, and quality of life assessment for the indigent population undergoing total hip or knee arthroplasty. The study split 226 subjects into psychologically distressed or non-psychologically distressed groups and surveyed them three weeks preoperatively. The psychologically distressed group had significantly lower measures before surgery for seven out of eight of the short form-36 questionnaire categories, which measure self-reported functional health and well-being, as well as for the Harris Hip Score, and the Knee Society Score. Many psychosocial factors like anxiety, depression, and somatization syndrome were identified as barriers to positive treatment outcomes in patients with chronic pain conditions, and were reported to be associated with lower functional outcome scores as well as patients' self-perceived recovery after surgery. It was also shown that psychological distress can act as a significant predictor of measurable outcomes, including the patient's self-rated improvement. The psychologically distressed group consistently reported poorer scores on the various self-report measures of pain, function, disability, and quality of life. However, there were no significant differences between groups based on objective evaluations by physicians using either the Harris Hip Score or Knee Society Score. Howard et al. concluded that initial pre-surgery reports of high levels of pain and disability and low levels of function and quality of life scores appear to be attributable to the psychosocial status of the patient.

4.2 Influence of depressive burden on recovery

In a five-year follow-up study, Pakarinen et al.⁶ reported that lumbar spinal stenosis patients presenting with depressive burden (i.e., depression or anxiety) using the Beck Depression Inventory (BDI) were associated with poorer surgical outcomes after decompressive surgery. Patients were divided into two groups based on BDI scores; those with high depressive burden (BDI of >40) and those with low depressive burden (BDI <39). This study reported clear differences in postoperative recovery measures between depressive burden groups. A high depressive burden was associated with greater disability at five-year follow up. Patients with high depressive burden also had poorer recovery from surgery throughout follow-up. Important correlations between high depressive burden and lower walking distances and Oswestry Disability Index (ODI) scores were also identified. Patients with minimal depression had a mean walking distance that was nearly twice that of patients with mild to moderate depression, and an ODI of 18, indicating minimal disability in contrast to patients with mild to moderate depression who had an ODI of 32, indicating moderate disability.

4.3 Fear-avoidance model and physical therapy

According to the fear-avoidance model of chronic pain, patients become more fearful to progress in physical therapy and either regress or do not progress in their treatment. Karels et al.⁴ reported that patients with arm, shoulder, and neck disorders who catastrophize are more likely to be fearful; fear of movement leads to increased avoidance and progresses to disuse depression and disability. These authors also reported that patients who catastrophize have significantly longer persistence of complaints versus patients who did not catastrophize. Moreover, fear of movement was a predictive factor in persistence of complaints at 6-month follow-up.⁴ These authors concluded that social and psychological factors including somatization, kinesiophobia, catastrophizing, and long duration of complaints at baseline evaluation were related to persistence of complaints such that 40% of patients had persisting arm, shoulder, or neck pain and discomfort at 6 months after treatment, influencing the patient's perception of their recovery.

Systematic review of best current evidence suggests that mental and behavioral health play significant roles in patients' physical health and outcomes after treatment of orthopaedic disorders. Anxiety and depression are common in patients with musculoskeletal pain and can significantly influence patients' perceived and actual recovery, healing, physical and mental health, satisfaction, and outcomes after surgical and non-surgical treatments. While the peer-reviewed literature clearly validates the influences of behavioral and psychosocial issues on patients, there is a major knowledge gap regarding the effects of behavioral interventions on outcomes after orthopaedic surgery. As such, there is a critical need to focus research on pre-operative and post-operative interventions that have the potential to positively influence recovery, healing, physical and mental health, satisfaction, and outcomes for at-risk patients. At the authors’ institution, research in this area is currently focused on patients undergoing osteochondral and meniscal allograft transplantation surgeries.

Despite continual improvements and technical advances in delivery of orthopaedic care, functional outcomes, restoration of quality of life, cost-effectiveness, and value, many orthopaedic procedures still fall below desired outcome levels even in physically healthy patients. Mental and behavioral health issues provide one explanation for this gap in orthopaedic healthcare. Collaborative care models—which promote an active partnership between the patient and medical professionals—have been reported to be beneficial at improving patient outcomes. Unfortunately, the confidence of physicians in handling psychosocial factors is typically low, and most surgeons avoid screening for behavioral health problems.⁷ In the study by Wegener et al.,⁷ more than half of the physicians surveyed did not feel properly equipped or have the strategies or time to address their patients’ psychosocial issues. In addition, many surgeons reported that their patients do not have appropriate access to mental health services, creating an environment where patients at risk for psychosocial issues are unable to receive needed care. In this study focusing on physician training and use of the Trauma Collaborative Care (TCC) model aimed at early screening and management of emotional distress and psychological comorbidities, surgeons became more comfortable discussing mental health with orthopaedic trauma patients after they had proper training, and surgeons who had the TCC model in place reported greater capabilities for handling psychosocial issues and making appropriate referrals for their orthopaedic trauma patients.

Available tools for assessing anxiety, depression, and post-traumatic stress disorder (PTSD) after orthopaedic injury and/or surgery include Recovery Assessment, Beck Depression Inventory-II (BDI-II), and Four-Dimensional Symptom Questionnaire (4DSQ). Recovery Assessment determines risk factors such as pain, PTSD, depression, and alcohol/tobacco use and combines protective factors such as resilience, social support, self-efficacy for return to work, and managing the financial burden of orthopaedic trauma.⁸ The Beck Depression Inventory-II (BDI-II) is a subjective screening tool that focuses on depression. This tool identifies and provides ratings for minimal to severe depression using a subjective scale based on a patient-reported survey. The Four-Dimensional Symptom Questionnaire (4DSQ) is a 50-item self-reported questionnaire that was developed to identify four dimensions of common psychological symptoms: distress, depression, anxiety, and somatization.⁸ This subjective questionnaire is able to distinguish general distress (e.g., a patient having a stressful day) from depression, anxiety, and somatization.

In order to move forward in appropriately intervening for patients, the critical unmet needs including gaps in knowledge, physician education and training, implementation of screening tools and methods, and collaborative care models with resources must be addressed. Well-designed long-term studies can then be conducted to provide evidence-based support for insurance covered screening and intervention programs that allow for proper education, training, and resources for healthcare providers and institutions. At the authors' center, this approach has been recently implemented for patients undergoing osteochondral and meniscal allograft transplantation surgeries and patients who are non-operatively managed for knee, hip, and ankle osteoarthritis and various health-related co-morbidities such as obesity or diabetes mellitus. Pre-treatment patient assessment and education, as well as post-treatment monitoring and counseling, are carried out by a team of healthcare professionals dedicated to these patient cohorts. The attending physicians on the team are responsible for managing the medical care of patients. A health behavior psychologist screens patients for risk of noncompliance based on documented patient-related factors (e.g., age, sex, body mass index, occupation, activities, attitudes, motivations, and understanding), behavioral and psychosocial issues (e.g., depression, anxiety, mental health), socioeconomic barriers (e.g., education level, employment, and insurance) and treatment-related factors (e.g., pain, length of post-treatment rehabilitation). The psychologist monitors and provides counsel to patients after treatment based on these assessments. Registered nurses coordinate patient care, communication, and education; manage physician orders and prescriptions; and reinforce expectations and compliance. Physical therapists provide inpatient therapy and provide or coordinate outpatient physical therapy to the patient's local outpatient physical therapist. Physical therapists also monitor and collect related outcomes data, compliance, and complaints. Dietitians and trainers provide pre- and post-treatment patient-specific assessments, management plans, and counseling. Clinical care faculty and staff collect and analyze physician- and patient-reported outcome measures, complications, and other related data. Data are entered into institutional review board-approved prospective registries to provide long-term monitoring and assessments with informed consent. Participating patients sign pain, rehabilitation, and compliance “partnerships” prior to treatment. The team holds in-person meetings on a weekly basis in order to optimize and coordinate care. The team works to identify at-risk patients, set appropriate expectations, continuously monitor outcomes, identify and address potential concerns and complications, and overcome barriers to better insure compliance. This approach combined with real-time analysis of registry data has been associated with an initial improvement in outcomes for these patients.^2,3

The limitations of this systematic review primarily involve the paucity of articles meeting inclusion criteria and the subjective nature of research in this field. While the available evidence indicates important associations for behavioral health and psychosocial issues with inferior outcomes after surgical and non-surgical treatments for orthopaedic disorders, patient outcomes are always highly multifactorial and often very disparate with respect to perception versus reality. As such, additional research is needed in order to provide clear recommendations for behavioral screening and interventions for orthopaedic patients so that recovery, healing, physical and mental health, satisfaction, perceived and actual outcomes, value, and cost effectiveness components of orthopaedic care can be optimized.

In conclusion, this systematic review of best current evidence indicates that psychological distress and untreated mental health issues are strongly associated with unfavorable outcomes after treatment of orthopaedic disorders, underscoring the need to incorporate behavioral screening and counseling into a comprehensive patient management protocol that improves outcomes for patients.