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The impact of patient grit, resilience, and ability to cope with stress on outcomes following total joint arthroplasty
, Tucker Callanana, Mohammad Dahera, Noah Gilreathb,c, Sarah Criddlea, John Milnera, Eric Cohena,c, Valentin Antocia,c
∗Corresponding author: Jonathan Liu. Jliu@uoi.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
With mental health gaining prominence in medical research, understanding the impact of emotional and psychological factors on surgical outcomes is increasingly important. This study evaluates whether patients’ coping skills, resilience, and grit influence outcomes such as length of stay (LOS), readmissions, pain, and function following total joint arthroplasty (TJA).
This retrospective review included 50 patients who completed validated preoperative assessments measuring grit, resilience, and coping strategies. Additional data were drawn from the WHO Well-being Index, SF-8 Health Survey, and FORCE-TJR database. Postoperative hospital metrics and patient-reported outcomes were collected and analyzed at the 12-month follow-up to evaluate correlations between preoperative psychological metrics and surgical outcomes.
Preoperative coping and grit scores demonstrated limited associations with clinical and patient-reported outcomes following TJA. Statistically significant correlations included SF-8 scores with 12-month quality of life (p = 0.017), activities of daily living (p = 0.002), and pain (p = 0.027). Higher STRESS scores were negatively correlated with quality of life (p = 0.015). While most associations were not significant, a trend toward significance was noted between grit and pain at 12 months postoperatively (p = 0.09).
Psychological factors such as coping and grit did not consistently correlate with postoperative outcomes in this cohort. However, preoperative quality of life and stress demonstrated significant correlations with patient reported outcomes at one year postoperatively. These findings underscore the need for targeted preoperative psychological interventions to optimize recovery. Future research should focus on refining assessment tools and exploring their predictive validity in larger cohorts.
III.
1 Introduction
Total joint arthroplasty (TJA) is a widely performed elective procedure for managing end-stage osteoarthritis (OA). With the aging U.S. population and rising obesity rates, the prevalence of OA and, consequently, the demand for TJA are projected to grow substantially.1,2 By 2040, the incidence of total hip arthroplasty (THA) and total knee arthroplasty (TKA) is expected to rise by 284 % and 401 % respectively.3 This anticipated spike underscores the urgency of identifying factors contributing to suboptimal postoperative outcomes. While patient-specific factors such as age, body mass index, gender, and comorbidities are established predictors of implant failure and revision surgery, the role of psychological traits remains underexplored.
Persistent symptoms or pain following TJA affect between 8 and 10 % of THA patients and up to 20 % of TKA patients.4,5 Pain-coping strategies therefore play a critical role in this population both preoperatively and postoperatively. Adaptive coping skills are believed to foster better results through a positive psychological framework, while maladaptive strategies may exacerbate recovery challenges.6,7 Although the link between coping strategies and postoperative outcomes is not yet fully elucidated, evidence strongly associates depression and anxiety with poorer surgical outcomes.8 Studies have shown that patients with depression report heightened pain perception and demonstrate significantly lower scores on functional measures such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).9
Patients with unresolved postoperative pain and limited functionality often require prolonged medical care or revision surgery, negatively affecting their quality of life and imposing a financial burden on healthcare systems.4 A study by Ayers et al. demonstrated that integrating a mental component into preoperative evaluations significantly improved the prediction of six-month functional outcomes after TJA.10 These findings emphasize the potential of psychological resilience to identify at-risk patients and implement preventative measures.
This study aims to evaluate the predictive value of preoperative coping skills and grit on post-operative outcomes following THA or TKA, thereby contributing to a more nuanced understanding of psychological influences on recovery.
2 Methods
2.1 Study design and participants
This study was a retrospective chart review, approved by the institutional review board-approved (IRB), focusing on patients at a single institution who underwent primary THA or TKA between January 1, 2018 and December 21, 2020. Inclusion criteria required patients to have completed standard IRB-approved preoperative surveys, including the preoperative risk assessment, stress and coping skills questionnaire, World Health Organization (WHO) Five Well-Being Index, and Medical Outcomes Survey Short Form-8 Questionnaire (SF-8). Demographic information including height, weight, body mass index (BMI), and clinical metrics such as length of hospital stay (LOS) and postoperative readmissions were retrospectively collected. Additional data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) registry were also analyzed.
2.2 Data collection and analysis
As part of standard preoperative care in our institution, patients undergoing TJA were provided with IRB-approved questionnaires during their preoperative visit, conducted one to six weeks prior to surgery. All patients were registered in FORCE-TJR, a national database for TJA surgical and patient-reported outcomes. Postoperatively, they were prompted to update their FORCE-TJR profiles at 3-, 6- and 12-months. The analysis aimed to evaluate the relationships between preoperative psychological factors and postoperative outcomes.
2.3 Preoperative visit outcome measures
Four surveys were administered to patients during their preoperative visit to assess individual coping skills, grit, and mental resilience. The SF-8 survey comprised eight questions evaluating general health perception, physical functioning, physical role functioning, pain, vitality, social functioning, mental health, and emotional role functioning over the past four weeks. Patients responded using a 5- or 6-point Likert scale, and higher scores indicating better subjective health and function.
Quality of life was assessed using the WHO (Five) Well-Being Index, a validated tool for evaluating mental wellbeing.11 This survey required patients to indicate their agreement with five statements using a 5-point Likert scale. Total scores ranged from 0 to 25, with higher scores reflecting better mental wellness and overall quality of life.
Stress coping abilities were evaluated utilizing a variation of the Brief COPE survey (STRESS).12 Patients rated their agreement with 28 different statements on a 4-point scale. The summed responses provided a total score out of 112 points, correlating with the respondent's predominant coping style. Higher scores indicated enhanced coping skills across subsets such as problem-focused coping skills, emotion-focused coping, and avoidant coping behavior.
The final preoperative assessment utilized an IRB-approved eight item survey, designed to evaluate a patient's grit (GRIT). Patients selected one of five responses for each statement, scored on a 5-point scale. Individual scores for all four surveys were summed to calculate a total cumulative score, with higher values reflecting greater grit and resilience.
2.4 Postoperative outcome measures
Patient's postoperative QoL, ADLs, and pain were evaluated at 12-months following TJA through the FORCE-TJR database. For patients undergoing THA, outcomes were evaluated utilizing the Hip Disability Osteoarthritis Outcome Score (HOOS), while TKA patients were assessed using the Knee Disability Osteoarthritis Outcome Score (KOOS). Both HOOS and KOOS are validated instruments widely used in clinical research to evaluate pain and functional outcomes specific to hip and knee arthroplasty.13,14 Hospital records were retrospectively accessed for data regarding the patients LOS and readmissions.
2.5 Statistical analysis
Descriptive statistics, including mean values and standard deviation or population percentages were calculated for patient demographics, survey scores, and postoperative FORCE-TJR outcomes. Pearson correlation coefficients were used to examine relationships between preoperative survey measures and FORCE-TJR outcome measures. Logistic regression models evaluated differences in mean survey scores between (1) patients with a LOS <1 day and those with a LOS ≥1 day and (2) patients with no readmissions versus those with at least one readmission. Pairwise comparisons were conducted using orthogonal contrasts within the models. Additionally, subgroup analyses were conducted for THA and TKA cohorts to identify procedure-specific trends. All statistical analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC) with a significance threshold set at p < 0.05.
3 Results
3.1 Demographics & survey scores
A total of 50 patients met inclusion criteria and were included in the analysis. The average age was 69.5±8.5 years, 64 % of the cohort was female, and 90 % identified as White. Equal representation of primary THA (50 %) and TKA (50 %) procedures was observed. Baseline survey scores revealed an average GRIT score of 32.1 ± 3.8, STRESS score of 69.9 ± 13.9, WHO score of 14.6 ± 6.5, and SF-8 score of 23.6 ± 5.2. Additional details on demographics and survey results are presented in [Table 1].
| Variable | Mean ± SD or n (%) |
| Number of patients | 50 |
| Patient Characteristics | |
| Age (years) | 69.5 ± 8.5 |
| Gender | |
| Female | 32 (64 %) |
| Male | 18 (36 %) |
| BMI (kg/m 2 ) | 29.5 ± 4.6 |
| Race | |
| White | 45 (90 %) |
| Asian | 1 (2 %) |
| Refused | 4 (8 %) |
| SX | |
| L THA | 9 (18 %) |
| R THA | 18 (36 %) |
| L TKA | 15 (30 %) |
| R TKA | 8 (16 %) |
| Scores | |
| GRIT | 32.1 ± 3.8 |
| STRESS | 69.9 ± 13.9 |
| WHO | 14.6 ± 6.5 |
| SF8 | 23.6 ± 5.2 |
| Total Score | 140.3 ± 16.1 |
| Outcomes | |
| Length of Stay | 1.2 ± 0.6 |
| Length of Stay > 1 day | 7 (14 %) |
| At least 1 Readmission | 17 (34 %) |
| p12m_ADL | 85.6 ± 15.4 |
| p12m_PAIN | 83.9 ± 16.7 |
| p12m_QOL | 77.1 ± 18.8 |
3.2 Correlation analysis
Significant correlations were observed between SF-8 scores and all three 12-month postoperative outcomes: QoL (r = 0.34, p = 0.017), ADL (r = 0.42, p = 0.002), and pain (r = 0.31, p = 0.027). Conversely, STRESS scores demonstrated a negative correlation with postoperative QoL (r = −0.34, p = 0.015). Subgroup analysis demonstrated that these correlations were stronger in the TKA cohort compared to the THA cohort. Notably, significant associations were observed between SF-8 scores and all FORCE-TJR outcomes, as well as between STRESS scores and QoL, in the TKA group. In contrast, no significant correlations were identified in the THA group. These findings highlight potential differences in how psychological factors impact recovery across procedures. Detailed correlation coefficients for all measures are available in [Table 2].
| Outcome | GRIT | STRESS | WHO | SF8 | Total Score |
| p12m_ADL | −0.11 (p = 0.468) | −0.04 (p = 0.863) | 0.12 (p = 0.394) | 0.42 (p = 0.002∗) | −0.07 (p = 0.625) |
| p12m_PAIN | 0.03 (p = 0.848) | −0.24 (p = 0.092) | 0.13 (p = 0.372) | 0.31 (p = 0.027∗) | −0.05 (p = 0.739) |
| p12m_QOL | −0.11 (p = 0.435) | −0.34 (p = 0.015∗) | 0.15 (p = 0.283) | 0.34 (p = 0.017∗) | −0.15 (p = 0.293) |
| THA | |||||
| Outcome | GRIT | STRESS | WHO | SF8 | Total Score |
| p12m_ADL | −0.02 (p = 0.927) | −0.27 (p = 0.059) | 0.04 (p = 0.848) | 0.27 (p = 0.166) | 0.10 (p = 0.618) |
| p12m_PAIN | 0.10 (p = 0.626) | −0.13 (p = 0.532) | 0.01 (p = 0.961) | 0.163 (p = 0.415) | 0.01 (p = 0.966) |
| p12m_QOL | −0.06 (p = 0.775) | −0.10 (p = 0.622) | 0.16 (p = 0.436) | 0.30 (p = 0.128) | −0.11 (p = 0.602) |
| TKA | |||||
| Outcome | GRIT | STRESS | WHO | SF8 | Total Score |
| p12m_ADL | −0.26 (p = 0.234) | −0.05 (p = 0.050) | 0.20 (p = 0.356) | 0.49 (p = 0.017∗) | −0.26 (p = 0.225) |
| p12m_PAIN | −0.09 (p = 0.700) | −0.40 (p = 0.062) | 0.242 (p = 0.265) | 0.31 (p = 0.027∗) | −0.14 (p = 0.528) |
| p12m_QOL | −0.23 (p = 0.28) | −0.62 (p = 0.002∗) | 0.17 (p = 0.437) | 0.43 (p = 0.039∗) | −0.41 (p = 0.050) |
3.3 Logistic regression
Logistic regression analysis comparing patients with “outpatient procedures” (LOS <1 day, n = 43) to those with “inpatient procedures” (LOS ≥1 day, n = 7) revealed significantly lower average SF8 scoring in the inpatient group (19.4 ± 5.3 vs 24.3 ± 4.9, p = 0.019). No significant differences were found for GRIT, STRESS, or WHO scores between these groups. Additionally, comparisons of GRIT, STRESS, WHO, SF-8, and total score measures between patients with no readmissions (n = 33) and those with at least one readmission (n = 17) showed no significant differences. Further details are provided in [Table 3] and [Table 4].
| Scores | Outpatient LOS <1 day (n = 43) | Inpatient LOS ≥1 day (n = 7) | P value |
| GRIT | 32.1 ± 3.7 | 31.9 ± 5.0 | 0.858 |
| STRESS | 68.6 ± 14.3 | 78.3 ± 5.9 | 0.086 |
| WHO | 15.3 ± 6.0 | 10.9 ± 8.2 | 0.096 |
| SF8 | 24.3 ± 4.9 | 19.4 ± 5.3 | 0.019∗ |
| Scores | No Readmission (n = 33) | At Least 1 Readmission (n = 17) | P value |
| GRIT | 31.9 ± 4.0 | 32.6 ± 3.6 | 0.522 |
| STRESS | 68.5 ± 14.8 | 72.8 ± 11.8 | 0.306 |
| WHO | 14.7 ± 5.9 | 14.5 ± 7.6 | 0.896 |
| SF8 | 23.9 ± 5.7 | 23.1 ± 4.0 | 0.599 |
4 Discussion
The primary objective of this study was to determine whether preoperative measures of patient grit and coping abilities were associated with patient-reported and clinical outcomes following THA or TKA. These elective procedures demand substantial patient participation and commitment to achieve optimal results, given the significant post-operative pain and extensive rehabilitation involved. It is hypothesized that patients with better pre-existing well-being, grit, and coping mechanisms would demonstrate enhanced recovery and benefit from arthroplasty.
The preoperative SF-8 survey, measuring health-related quality of life (QoL), revealed a significant positive correlation with all three 12-month postoperative outcomes: ADL, pain, and QoL. The SF-8 measures health-related quality of life through factors such as general health perception, physical functioning, and mental health.15 This suggests that patients with better baseline perceptions of health, quality of life and functionality derive greater benefit from arthroplasty. Conversely, patients with a lower preoperative quality of life may perceive less improvement, even with similar clinical outcomes. Pain, a multifactorial construct, also showed a significant association with SF-8 scores, potentially reflecting effective pain-coping strategies in patients with higher scores.16 Previous studies, including Hidaka et al., have linked pain catastrophizing with poorer QoL outcomes.17 Notably, preoperative pain severity does not appear to impact pain catastrophizing postoperatively.18 These findings underscore the complexity and variable nature of patients’ pain perceptions and coping mechanisms.
The STRESS survey scores showed a negative correlation with 12-month postoperative QoL following TKA. Higher STRESS scores represent problem-based coping mechanism skills while lower scores reflect an avoidant coping mechanism. Surprisingly, these findings suggest that patients employing problem-based coping strategies approach may report worse QoL measures at one year postoperatively This could be attributed to their focus on addressing active issues, which may make them more likely to openly and honestly report negative findings in surveys. Conversely, patients with avoidant coping mechanisms may not follow-up with surveys or have not reconciled with their challenges, or be reluctant to admit difficulties, potentially skewing their patient reported outcomes.
Interestingly, no statistically significant associations were identified between the WHO or GRIT scores. Grit, defined as “perseverance and passion for long term goals” has recently gained attention across multiple fields of medicine and society.19 Its role in predicting success and positive outcomes has garnered public interest, particularly after being validated as a predictor of academic and athletic achievements.20,21 In medical contexts, higher grit scores have been associated with improved outcomes in various scenarios.22–26 However, its relevance to patients undergoing total hip and knee arthroplasty has not been well-developed.
In a study by March et al. patients with differing degrees of resilience showed no differences in LOS following TKA. Instead, depression and anxiety had significant association with longer hospital stays.27 In this study we did not observe significant correlations between grit or resilience and post-operative subjective or clinical outcomes. It is possible that further refinement of the GRIT survey and higher-powered studies may validate GRIT scores as a positive predictor of improved outcomes. Additionally, investigating GRIT's influence on different stages of rehabilitation may provide valuable insights into its impact on recovery.
Subgroup analysis revealed that psychological measures had stronger correlations with outcomes in the TKA cohort than in the THA cohort. This discrepancy may arise from the more pronounced and predictable functional improvements typically seen with THA, which can diminish the relative influence of psychological factors.28 THA, often described as the “operation of the century”29 tends to yield substantial post-operative improvement, potentially overshadowing the effects of preoperative psychological traits (STRESS and SF8) compared to the more variable recovery associated with TKA.
4.1 Limitations
The study has a limited sample size (n = 50), which may affect power and its generalizability, though to our knowledge, represents one of the largest investigations into the effects of pre-operative psychological traits like coping and grit on TJA outcomes. limit its generalizability. Factors such as depression, dissatisfaction, logistical challenges, and health complications may have affected follow-up adherence, introducing potential selection bias. Additionally, combining THA and TKA patients for analysis, despite procedural differences, may have diluted findings. Although the one-year follow up was selected as an accepted point of maximal improvement, earlier time points (e.g., three and 6 months) may provide better assessment and insights into the influence of grit and coping abilities on the rehabilitation process.
Further research with larger sample sizes, higher statistical power, and refined assessment tools is necessary to validate these findings and explore the potential for targeted preoperative psychological interventions to optimize recovery and patient satisfaction.
5 Conclusion
Patients' ability to cope with stressors and their level of grit did not demonstrate a significant impact on patient reported outcomes following TJA. However, preoperative quality of life and stress/coping scores were most strongly associated with the quality-of-life measures at 12 months TJA, especially in patients undergoing TKA. Our findings suggest that intrinsic patient factors play an important, albeit intangible, role in the recovery process and ultimate outcomes. Further refinement of assessment tools and larger, well-powered studies are necessary to validate the potential of existing surveys as a predictive tools for patient improvement after arthroplasty, especially TKA. These advancements could provide valuable guidance for arthroplasty surgeons in pre-operative patient selection and education. Additionally, implementing patient specific interventions, such as targeted therapy regimens and psychological counseling, may enhance post-operative rehabilitation and improve outcomes for high-risk patients.
CRediT authorship contribution statement
Jonathan Liu: Writing – original draft. Tucker Callanan: Writing – original draft. Mohammad Daher: Writing – original draft. Noah Gilreath: Collecting data. Sarah Criddle: Collecting data. John Milner: Collecting data. Eric Cohen: Writing – review & editing. Valentin Antoci: Writing – review & editing.
Ethics
All patients signed an informed consent form and procedures were conducted according to the Declaration of Helsinki.
Consent
All patients signed an informed consent form and procedures were conducted according to the Declaration of Helsinki.
Funding
None.
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