1 Introduction

Pain is defined as “an unpleasant sensory and emotional experience in the presence of actual or potential tissue damage”.¹ Traditionally in the biomedical model of medicine, illness is exclusively related to biological factors without regard for psychosocial factors. There is good evidence that the biomedical model is an oversimplification and a biopsychosocial model is more accurate. Pain intensity does not necessarily directly correlate with the degree of tissue injury and pain is a personal experience that is shaped not only by the degree of tissue injury but also an individual's psychological cognitions and social context.^2–4

Individuals who experience musculoskeletal injury due to trauma or degeneration may construe the experience as being unjust, and that they are victims.^5–7 In the context of injury and chronic pain, perceived injustice is defined as “an appraisal process characterized by a tendency to construe one's losses as being severe and irreparable, and to attribute blame to others for one's own suffering”.^6,8 This sense of injustice leads to anger and distorted attention which in turn leads to poor self-management and catastrophising.⁹ There is strong evidence in the literature that higher levels of injustice are associated with higher levels of pain, disability, reduced function, and higher levels of depressive symptoms in patients who experience musculoskeletal (MSK) pain10,11. This has significant social, financial and medicolegal implications with the resultant symptoms resulting in increased worry and fear of movement, poor rehabilitation and subsequent delayed return to work as well as higher levels of litigation.^12–14 The level of injustice an individual perceives in response to a given situation can be quantified, and the Injustice Experience Questionnaire (IEQ) has been well validated as a tool for quantifying and characterising the degree of injustice an individual experiences following an event^8,15 and has been used in many studies to examine the relationship between perceived injustice and these outcome measures in many studies in patients who have experienced both chronic and acute MSK pain.

Orthopaedic surgeons frequently deal with pain and the resultant loss of function secondary to a wide spectrum of pathology; from severe acute trauma, to the mild and self-limiting, to the consequences of normal aging and degeneration. Subsequently pain relief and restoration of function are primary goals of surgery in many traumatic and elective orthopaedic patients.¹⁶ Despite this, there is evidence suggesting that many patients experience chronic pain following orthopaedic surgery and persistent post-operative pain is a common cause of repeat clinic visits following surgery.¹⁷ Given pain is not simply related to tissue injury, an understanding and appreciation of the psychosocial factors that influence pain and functional outcomes and potential therapeutic interventions that can be undertaken is of huge importance to orthopaedic surgeons.¹⁸

One of the interventions that has been shown to benefit patients with high levels of injustice is a strong therapeutic alliance between patient and clinician. Humanising and empathising at an early stage can help to mitigate some of the negative cognitions, anger and confrontation and help foster a strong therapeutic alliance.¹⁹ As well as this, patient centred care and the formation of a therapeutic alliance between clinician and patient are widely accepted as being a key component of modern medical professionalism and²⁰ as being an essential non-technical skill for the modern surgeon.²¹

Given high levels of perceived patient injustice and the resultant anger and confrontation can lead to a deterioration in the therapeutic alliance, and that there are early interventions to help prevent this from occurring, this is a potentially an important area in the overall holistic approach to orthopaedic patients.²² Furthermore, in an era where patient satisfaction and Patient Reported Outcome Measures (PROM's) are increasingly being used as a marker for treatment success, as well as to inform clinical decision-making, health policy and increasingly impact financial reimbursement in certain jurisdictions, perceived patient injustice can impact patients, individual clinicians as well as healthcare systems as a whole.²³

While injustice has been examined in the context of predicting pain outcomes and is commonly utilized by pain specialists and psychologists alike in this regard, we suspect the awareness of the concept of patient injustice and application of interventions amongst orthopaedic surgeons is low. Subsequently, based on the wider evidence that perceived patient injustice plays a significant role in poor outcomes in MSK pain, and the potential patient benefits of increased clinician awareness we decided to perform a systematic search of the literature to see if there was any evidence of this phenomenon occurring in patients undergoing trauma and elective orthopaedic surgery.

2 Materials and Methods

3 Results

4 Discussion

This systematic review investigates the association between perceived patient injustice and pain, mental health and functional outcomes in trauma and elective orthopaedic surgery patients. The findings of this review were consistent with wider findings related to chronic MSK pain-that there is a strong association between higher levels of perceived injustice and higher levels of mental anguish, pain intensity and interference and decreased levels of function as well as increased disability and prolonged return to work times in orthopaedic surgery patients.

One study in the review identified a strong association between perceived injustice and depression in a mixed cohort of trauma and elective orthopaedic patients.²⁴ While many patients adapt well following injury and trauma, there is evidence that higher levels of perceived injustice and the perception of an external locus of control surrounding an injury lead to poor coping strategies resulting in worse psychological and pain related outcomes.^12,29 The association between injustice and depression is an important finding in orthopaedic patients as higher levels of depression have been intrinsically linked to poorer rehabilitation outcomes in patients with orthopaedic injuries³⁰ as well as higher levels of long term pain31–33. Rehabilitation is a key stage in the recovery after any orthopaedic surgery and many of the benefits that can be gained from orthopaedic intervention are dependent on high quality rehabilitation post operatively. Therefore, identification of patients who may be at risk of developing depressive symptoms, as well as the subsequent possible poor engagement in rehabilitation programmes is of interest to orthopaedic surgeons. Identification of high levels of perceived patient injustice at an early stage may serve as predictive for patients who are at high risk of developing depressive symptoms and are subsequently at higher risk of poor outcomes. Early identification of this risk and early attempts to provide a higher level of psychological and social support may help to mitigate this risk and subsequently improve patient outcomes.

Consistent with these observations, three studies were identified with a strong association between higher levels of perceived injustice and pain intensity and interference. There was a mixture of trauma and elective patients in these studies, as well as pre and post-operative patients. Elective patients pertained to patients with knee osteoarthritis (OA) who were undergoing Total Knee Replacement (TKR).⁶ It is worth noting that these patients with OA had elevated levels of injustice both pre and post operatively, however, the mean injustice score was considerably lower than that of those in other studies who had traumatic orthopaedic injuries. This is suggestive that for some individual's trauma and the attribution of fault to others is intrinsically linked to traumatic injuries, however, higher elevations of perceived injustice in the elective orthopaedic population is potentially hugely important. Patient satisfaction post TKR has traditionally been lower than that of Total Hip Replacement (THR) with satisfaction rates in the literature reported as being between 80 and 100%.³⁴ Pain and reduced function are the most common complaints in patients who are unhappy post TKR. In recent times, there has been a move towards Enhanced Recovery After Surgery (ERAS) programmes in patients who are undergoing joint replacement.³⁵ ERAS programmes are a multidisciplinary team approach to the surgical patient and has been associated with reduced length of hospital stay, readmission rate and improved functional recovery. ERAS can be a key component of patient centred care and empower patients in their surgical journey through education and by minimising physical and psychological stress post operatively.³⁶ It stands to reason that in the elective setting, identifying patients pre operatively who may have high levels of perceived injustice and providing them with the appropriate psychological support and coping mechanisms may help to alleviate some of the adverse effects associated with higher levels of injustice by allowing for better engagement with the surgical process, formulating therapeutic alliances with all members of the care team and by better equipping them to engage with rehabilitation.³⁷

This is also true for patients who undergo traumatic injury. These patients have higher levels of injustice compared to the elective orthopaedic populations identified, however, the correlations between pain and loss of function remain true in this cohort. Surgery and surgical intervention in these patients is often more time critical then that of their elective counterparts and as such there may not be the facility for formal ERAS in the immediate pre-operative period. However, as clinicians there is an opportunity to recognise the at-risk patient with higher levels of perceived injustice. By identifying such individuals, humanising and empathising with them early in the process, one can help foster the therapeutic alliance from the outset and potentially avoid the confrontation and anger that can arise as a result of this, as well as potentially the pain and functional adverse events that are intrinsically linked to a perceived external locus of control.^{19,22,38–40} Subsequently, we feel that awareness of this concept amongst orthopaedic surgeons is important and that training and the development of these non-technical skills in interacting with such patients is an important skill in the arsenal of the modern orthopaedic surgeon.

There are a number of limitations to this review and our resultant conclusions. First of all, there are only 5 studies in our systematic review and the majority of these studies deal with patients who have undergone orthopaedic trauma. One study deals exclusively with elective orthopaedic patients and one is a mixed population of trauma and elective patients. This is a very heterogenous group of patients and should be considered as distinct entities, which is a confounding factor and a limitation of our extrapolations and applicability. Furthermore, given the variation and complexity of trauma there is potential huge confounding within this patient population as well. There is significant variation within the orthopaedic injuries that have been mentioned ranging from those with major trauma and an Injury Severity Score (ISS) of greater than 15 to isolated long bone fractures in haemodynamically stable patients and care should be taken in applying findings from a pooled analysis to such a diverse group of patients. As well as this, perceived injustice is rooted in psychological and social cognitions²⁶ and thus the cultural context of individual studies needs to be taken into account. This is a heterogenous group of patients across 3 continents, and care should be taken in applying these results to different patient populations, although it is worth noting that the majority of studies, demonstrated the association regardless of geographical location. With respect to comparability all studies with the exception of one used the IEQ to measure injustice. One study used the QPI which is wording variation of the IEQ and is thus comparable. It is likely that the wording variation relates to a Spanish translation of the IEQ in this particular study. The QPI has been validated as a tool to measure perceived injustice, however, caution must be used in comparing these results. Furthermore, different scoring systems for pain intensity, interference function and disability are utilized throughout the studies, as well as different statistical analysis based on individual study populations mean that the results are not amenable to meta-analysis, which would strengthen the findings. It is important to note however, each study independently identified an association between perceived injustice and pain and functional outcomes in orthopaedic patient populations. While the overall conclusions of this systematic review indicate that there is a strong correlation between perceived injustice and adverse pain and functional outcomes in orthopaedic surgery patients, particularly when interpreted in the context of the wider chronic MSK pain literature, it is clear that further research is needed before definitive conclusions can be drawn.

5 Conclusions

There is an association between perceived patient injustice and adverse pain and functional outcomes in patients who undergo orthopaedic surgery. This is a concept that orthopaedic surgeons should be aware of, as there are simple interventions that can be done to minimise this and potentially improve patient outcomes. Further research in this area is needed in distinct trauma and elective orthopaedic patient populations and there is great potential for further collaborative research studies to be conducted in the future.

Funding statement

No funding or sponsorship sources to declare.

Author statement

MCGF-Formal analysis, writing-original draft, writing-review and editing.

JM-Formal analysis, writing-review and editing.

DMB-Formal analysis.

FC-Conceptualisation, writing-review and editing.

DCH-Conceptualisation, writing-review and editing.