Abstract
Background:
Psychiatric comorbidities have been shown to influence outcomes of various orthopedic pathologies. This study aimed to compare rates of delayed scaphoid union and surgical intervention for fractures in patients with and without comorbid psychiatric diagnoses.
Methods:
A matched retrospective cohort study was performed using the PearlDiver database to determine the association of depression, anxiety, bipolar disorder, and schizophrenia with delayed union rates within 3 and 6 months and rates of nonacute surgical intervention (fixation or grafting) within 6 and 12 months of scaphoid fracture. Analyses were completed using multivariate logistic regression.
Results:
Among 20 340 patients, a comorbid psychiatric diagnosis was associated with increased rates of delayed scaphoid union at 3 months (odds ratio [OR] = 1.29; 95% confidence interval [CI], 1.14-1.45) and 6 months (OR = 1.23; 95% CI, 1.10-1.38). At 3 months, women with any psychiatric disorder (OR = 1.58; 1.29-1.66), depression (OR = 1.68; 1.31-2.17), and schizophrenia (OR = 5.32; 95% CI, 1.06-26.79) were more likely to experience delayed union, with similar results at 6 months. Men with bipolar disorder experienced increased delayed union rates at 6 months (OR = 1.40; 1.03-1.91). A comorbid psychiatric diagnosis (OR = 1.10; 1.01-1.20) was associated with increased rates of surgical intervention, whereas schizophrenia was associated with decreased rates (OR = 0.58; 0.34-0.99).
Conclusion:
Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. These results underscore the importance of understanding factors that may place patients at risk of impaired recovery.
Keywords: hand, fracture/dislocation, diagnosis, scaphoid, wrist, surgery, specialty, depression, nonunion, anatomy
Introduction
Acute scaphoid fractures account for upward of 80% of all carpal bone fractures, with union rates of nondisplaced injuries at 90% to 95% after immobilization and cast treatment.1,2 While less common, delayed union of scaphoid fractures does occur, with varying rates from 5% to as high as 50%.3,4 Factors that influence the likelihood of delayed union include fracture location, fracture displacement, instability, and time to treatment.2,3 Delayed union, and more specifically, nonunion, is of paramount importance to identify, as it can result in carpal malalignment and progressive radiocarpal arthrosis. Factors outside the nature of the injury that influence delayed scaphoid union are less understood. Several reports have documented that smoking negatively affects bone mineral density (BMD) by altering calcium and vitamin D metabolism and hormone levels, such as estrone and estradiol.5 -8 As a result, smoking has been associated with an increased risk of fracture, slowed healing rates, and higher nonunion rates. 9
Recent studies have attempted to understand the effect of psychiatric disorders, such as depression and anxiety, on postoperative complications following total joint arthroplasty and arthroscopy.10,11 In patients undergoing total knee arthroplasty (TKA), preoperative depression was associated with higher rates of periprosthetic fractures, broken prosthetic joints, and both mechanical loosening and dislocation of the prosthetic joint. 10 Our study sought to elucidate the association of comorbid psychiatric disorders with rates of delayed union following a scaphoid fracture as well as their association with the likelihood of undergoing a nonacute surgical intervention, whether open reduction internal fixation or bone grafting. We hypothesized that psychiatric comorbidities are associated with higher rates of delayed scaphoid union within 3 and 6 months of the initial scaphoid fracture and higher rates of surgical intervention within 6 and 12 months of the fracture.
Materials and Methods
A retrospective analysis was performed using PearlDiver (PearlDiver Technologies) to query for de-identified data within the Mariner database—a collection of medical records for more than 150 million patients. Patients with any type of scaphoid fracture were filtered using International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes (Supplemental Table 1). To allow 6-month follow-up time, only scaphoid fractures that occurred between January 1, 2010, and October 1, 2020, were included. In addition, to ensure full medical records, only patients active for at least 1 year before and 6 months after the scaphoid fracture were included. Exclusion criteria included a previous diagnosis of metastatic cancer, mitochondrial disease, or connective tissue disease. Current Procedural Terminology (CPT) codes (25628—open treatment of carpal scaphoid navicular fracture, with or without internal or external fixation, 25440—repair of nonunion, scaphoid navicular bone, with or without radial styloidectomy) were used to identify all patients who underwent surgical intervention to address their fracture. To identify and exclude patients who underwent acute surgical intervention to address their fracture, patients initially treated with surgery and who did not undergo nonoperative management during the first month after their injury were excluded (Figure 1). All criteria ICD-9 and ICD-10 codes are presented in Supplemental Table 2.
Figure 1.
Flowchart depicted the sample selection, the number of patients excluded, and the reasons for excluding those patients.
Using ICD-9 and ICD-10 codes, patients older than 10 years with scaphoid fractures and at least one of the following psychiatric disorders were identified: depression, anxiety, bipolar disorder (I or II), or schizophrenia. Patients with any one of these psychiatric disorders were included in the “Recent Psychiatric Diagnosis” group (experimental group), whereas patients without a psychiatric diagnosis were included in the “No Psychiatric Diagnosis” group, which served as the control for this study. After identification, 1:1 matching was performed to control for age, sex, Charlson Comorbidity Index (CCI), tobacco use, diabetes, osteoporosis, and osteoarthritis (Table 1). A second round of matching controlling for the same factors was performed for each individual psychiatric diagnosis to better compare rates of delayed scaphoid union between the specific diagnosis and the respective control.
Table 1.
Comparison of the Characteristics of Experimental and Control Cohorts Before and After Matching.
| Characteristic | Unmatched | Matched | ||||
|---|---|---|---|---|---|---|
| Recent psychiatric diagnosis a | No psychiatric diagnosis | P value | Recent psychiatric diagnosis a | No psychiatric diagnosis | P value | |
| n = 13 571 | n = 50 250 | n = 10 170 | n = 10 170 | |||
| Sex, female (%) | 8112 (59.8) | 21 459 (42.7) | <.001 | 5761 (56.6) | 5761 (56.6) | 1.000 |
| Age, mean ± SD | 45.3 ± 19.5 | 38.4 ± 22.0 | <.001 | 43.3 ± 20.0 | 43.3 ± 20.0 | 1.000 |
| CCI, mean ± SD | 1.9 ± 2.3 | 0.7 ± 1.5 | <.001 | 1.1 ± 1.4 | 1.1 ± 1.4 | 1.000 |
| Comorbidities (%) | ||||||
| Diabetes mellitus | 3645 (26.9) | 7512 (14.9) | <.001 | 2030 (20.0) | 2030 (20.0) | 1.000 |
| Tobacco | 5637 (41.5) | 8141 (16.2) | <.001 | 3298 (32.4) | 3298 (32.4) | 1.000 |
| Osteoporosis | 1356 (10.0) | 2758 (5.5) | <.001 | 670 (6.6) | 670 (6.6) | 1.000 |
| Osteoarthritis | 4299 (31.7) | 8915 (17.7) | <.001 | 2630 (25.9) | 2630 (25.9) | 1.000 |
Note. CCI = Charlson Comorbidity Index.
Includes diagnoses of depression, anxiety, bipolar disorder, and/or schizophrenia.
The presence of delayed scaphoid union was identified using ICD-9 and ICD-10 codes (Supplemental Table 1). Rates of delayed union at 3 and 6 months were calculated for the combined group and for each individual diagnosis group, along with their respective control. After determining the number of fractures that resulted in delayed scaphoid union, CPT codes with same-day ICD-9 or ICD-10 codes for delayed union/nonunion were used to compare the likelihood of these patients undergoing nonacute surgical intervention within 6 and 12 months of the initial injury.
T tests and χ2 analyses were used to compare the demographic characteristics between experimental and control groups before and after the matching process. Multivariate logistic regression analysis was used to compare the rates of delayed scaphoid union for each experimental group and its respective control group while controlling for age, sex, CCI, osteoporosis, tobacco use, antidepressant medication use, and diabetes. The same analysis was used for sex- and age-specific (30 years and younger or 31 years and older) comparisons. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A value of P < .05 was the cutoff for statistical significance. All statistical analyses were performed using the R Statistical Package (Version 4.2.1; R Core Team 2022, Vienna, Austria) embedded within PearlDiver.
Results
A total of 63 847 patients with scaphoid fractures met the inclusion criteria, and 13 571 (21.3%) of them had a diagnosis of depression, anxiety, bipolar disorder, and/or schizophrenia within 1 year of their scaphoid fracture. Following the matching process, 10 170 patients were included in both the experimental and control group for further analysis. Table 1 shows the characteristic comparisons between the 2 cohorts before and after the matching process.
The rate of delayed scaphoid union at 6 months in the combined psychiatric diagnoses cohort was 8.7%. In the depression-, anxiety-, bipolar-, and schizophrenia-specific cohorts, the rates of delayed union were 8.4%, 9.0%, 11.8%, and 15.1%, respectively. The rate of delayed union in the control was 6.8%.
The overall multivariate logistic regression model (Table 2) demonstrated that patients in the combined psychiatric diagnoses cohort experienced delayed scaphoid union at increased rates at both the 3-month (OR = 1.29; 95% CI, 1.14-1.45) and 6-month (OR = 1.23; 95% CI, 1.10-1.38) marks compared with control. At the 3-month mark, patients with depression, anxiety, and bipolar disorder experienced significantly increased rates of delayed union, and at the 6-month mark, these rates remained at statistically increased levels for both the depression and bipolar cohorts. There was no difference in the rates of delayed union in the schizophrenia cohort at either the 3- or 6-month mark.
Table 2.
Overall Cohort Comparison of the Rates of Delayed Scaphoid Union Using Multivariate Logistic Regression.
| Likelihood of delayed union following a scaphoid fracture | ||
|---|---|---|
| Odds of nonunion | ||
| Cohort and time period | OR (95% CI) | P value |
| All included psychiatric diagnoses | ||
| 3 mo | 1.29 (1.14-1.45) | <.001 |
| 6 mo | 1.23 (1.10-1.38) | <.001 |
| Depression | ||
| 3 mo | 1.34 (1.15-1.55) | <.001 |
| 6 mo | 1.23 (1.07-1.42) | .004 |
| Anxiety | ||
| 3 mo | 1.20 (1.03-1.41) | .021 |
| 6 mo | 1.14 (0.98-1.32) | .080 |
| Bipolar | ||
| 3 mo | 1.44 (1.09-1.90) | .009 |
| 6 mo | 1.46 (1.13-1.89) | .004 |
| Schizophrenia | ||
| 3 mo | 1.39 (0.79-2.48) | .254 |
| 6 mo | 1.66 (0.97-2.87) | .066 |
Note. Multivariate logistic regression model included age, sex, Charlson Comorbidity Index, tobacco use, diabetes, antidepressant use, and osteoporosis. OR = odds ratio; CI = confidence interval.
Bold indicates statistical significance (P < .05).
In the female-specific model, female patients with comorbid psychiatric diagnoses were significantly more likely to experience delayed union at both the 3-month (OR = 1.58, 95% CI, 1.29-1.94) and 6-month (OR = 1.48, 95% CI, 1.23-1.79) marks (P < .001 for both) (Table 3). Similarly, female patients with a specific diagnosis of depression experienced significantly higher rates of delayed union at both the 3- and 6-month marks, whereas women with anxiety and schizophrenia only saw increased rates at the 3-month mark. The all-age female cohort with bipolar disorder experienced similar rates of delayed union compared with control. Several of these differences were also noted in the age-specific analyses, most notably in the combined psychiatric diagnoses cohort and the depression cohort.
Table 3.
Female- and Male-Specific Cohort Comparison of the Rates of Delayed Scaphoid Union Using Multivariate Logistic Regression.
| Likelihood of delayed scaphoid union at 3 and 6 mo following a scaphoid fracture | ||||
|---|---|---|---|---|
| Females | Males | |||
| Cohort and time period | OR (95% CI) | P value | OR (95% CI) | P value |
| Combined psychiatric diagnoses | ||||
| All patients | ||||
| 3 mo | 1.58 (1.29-1.94) | <.001 | 1.16 (1.00-1.34) | .056 |
| 6 mo | 1.48 (1.23-1.79) | <.001 | 1.12 (0.97-1.29) | .121 |
| ≤30 y | ||||
| 3 mo | 1.60 (1.07-2.41) | .024 | 1.12 (0.90-1.38) | .310 |
| 6 mo | 1.54 (1.05-2.27) | .027 | 1.07 (0.87-1.31) | .530 |
| >30 y | ||||
| 3 mo | 1.60 (1.26-2.02) | <.001 | 1.21 (0.98-1.49) | .079 |
| 6 mo | 1.49 (1.20-1.85) | <.001 | 1.16 (0.96-1.42) | .128 |
| Depression | ||||
| All patients | ||||
| 3 mo | 1.68 (1.31-2.17) | <.001 | 1.18 (0.97-1.42) | .092 |
| 6 mo | 1.43 (1.14-1.80) | .002 | 1.13 (0.94-1.35) | .190 |
| ≤30 y | ||||
| 3 mo | 1.58 (0.92-2.75) | .099 | 1.23 (0.93-1.62) | .139 |
| 6 mo | 1.40 (0.85-2.31) | .189 | 1.15 (0.88-1.48) | .305 |
| >30 y | ||||
| 3 mo | 1.70 (1.28-2.26) | <.001 | 1.16 (0.89-1.51) | .271 |
| 6 mo | 1.44 (1.11-1.86) | .006 | 1.12 (0.88-1.44) | .352 |
| Anxiety | ||||
| All patients | ||||
| 3 mo | 1.37 (1.07-1.76) | .014 | 1.11 (0.90-1.36) | .333 |
| 6 mo | 1.23 (0.98-1.55) | .072 | 1.08 (0.89-1.30) | .443 |
| ≤30 y | ||||
| 3 mo | 1.44 (0.88-2.39) | .145 | 0.90 (0.66-1.21) | .492 |
| 6 mo | 1.25 (0.80-1.98) | .331 | 0.93 (0.70-1.23) | .613 |
| >30 y | ||||
| 3 mo | 1.36 (1.03-1.81) | .033 | 1.34 (1.01-1.78) | .040 |
| 6 mo | 1.26 (0.97-1.64) | .080 | 1.21 (0.94-1.57) | .143 |
| Bipolar disorder | ||||
| All patients | ||||
| 3 mo | 1.62 (0.97-2.77) | .069 | 1.37 (0.99-1.90) | .057 |
| 6 mo | 1.59 (1.00-2.55) | .054 | 1.40 (1.03-1.91) | .031 |
| ≤30 y | ||||
| 3 mo | 1.56 (0.61-4.10) | .352 | 1.38 (0.84-2.27) | .209 |
| 6 mo | 1.29 (0.52-3.18) | .581 | 1.41 (0.88-2.28) | .159 |
| >30 y | ||||
| 3 mo | 1.67 (0.90-3.10) | .107 | 1.40 (0.91-2.15) | .126 |
| 6 mo | 1.74 (1.01-3.04) | .047 | 1.43 (0.96-2.14) | .082 |
| Schizophrenia | ||||
| All patients | ||||
| 3 | 5.32 (1.06-26.79) | .042 | 1.05 (0.56-1.98) | .879 |
| 6 | 3.58 (0.95-17.35) | .075 | 1.41 (0.78-2.57) | .259 |
| ≤30 y | ||||
| 3 mo | N/A | 1.000 | 1.01 (0.39-2.54) | .989 |
| 6 mo | N/A | 1.000 | 1.13 (0.45-2.84) | .787 |
| >30 y | ||||
| 3 mo | 4.61 (1.00-33.04) | .072 | 1.10 (0.46-2.65) | .824 |
| 6 mo | 3.05 (0.76-15.36) | .133 | 1.67 (0.76-3.75) | .204 |
Note. Multivariate logistic regression model included age, sex, Charlson Comorbidity Index, tobacco use, diabetes, antidepressant use, and osteoporosis. OR = odds ratio; CI = confidence interval.
Bold indicates statistical significance (P < .05).
In the all-age male-specific cohorts (Table 3), only those patients with bipolar disorder experienced statistically increased rates of delayed union at the 6-month mark. All other disorders among men demonstrated statistically similar rates of delayed union. The only age-specific cohort that experienced statistically greater rates of delayed union was the older than 30 years anxiety cohort (OR = 1.34, 95% CI, 1.01-1.78).
Patients with comorbid psychiatric diagnoses were significantly more likely to undergo nonacute surgical intervention within 6 months (OR = 1.10; 95% CI, 1.01-1.20) and 12 months (OR = 1.10; 95% CI, 1.01-1.19) to address delayed scaphoid healing compared with control (Table 4). No other psychiatric cohort underwent surgical intervention at increased rates compared with control. However, the schizophrenia cohort in both the combined analysis (OR = 0.58; 95% CI, 0.34-0.99) and the male-specific analysis (OR = 0.51; 95% CI, 0.28-0.93) underwent nonacute surgical intervention at significantly decreased rates within 6 months of their scaphoid fracture.
Table 4.
Comparison of the Likelihood of the Delayed Scaphoid Union Requiring Surgical Intervention Between Patients With a Recent Diagnosis of Depression, Anxiety, Bipolar Disorder, and/or Schizophrenia and Control Using Multivariable Logistic Regression.
| Likelihood of delayed scaphoid union requiring nonacute surgical intervention within 6 and 12 mo of fracture | ||||
|---|---|---|---|---|
| Cohort of interest | 6 mo | 12 mo | ||
| OR (95% CI) | P value | OR (95% CI) | P value | |
| Full psychiatric cohort | 1.10 (1.01-1.20) | .030 | 1.10 (1.00-1.19) | .042 |
| Depression | 1.05 (0.94-1.17) | .397 | 1.04 (0.93-1.16) | .474 |
| Anxiety | 1.04 (0.93-1.16) | .496 | 1.04 (0.93-1.17) | .452 |
| Bipolar | 0.87 (0.71-1.11) | .284 | 0.89 (0.71-1.10) | .280 |
| Schizophrenia | 0.58 (0.34-0.99) | .048 | 0.61 (0.36-1.03) | .065 |
| Female combined cohort | 1.14 (0.99-1.31) | .060 | 1.14 (1.00-1.31) | .054 |
| Depression | 1.17 (0.98-1.38) | .075 | 1.17 (0.99-1.38) | .063 |
| Anxiety | 1.13 (0.95-1.34) | .164 | 1.13 (0.95-1.34) | .155 |
| Bipolar | 1.01 (0.69-1.48) | .956 | 1.06 (0.72-1.55) | .770 |
| Schizophrenia | 1.09 (0.30-4.02) | .888 | 1.28 (0.38-4.55) | .692 |
| Male combined cohort | 1.08 (0.96-1.21) | .200 | 1.06 (0.95-1.19) | .285 |
| Depression | 0.97 (0.84-1.12) | .691 | 0.95 (0.83-1.10) | .522 |
| Anxiety | 0.98 (0.84-1.14) | .779 | 0.98 (0.85-1.14) | .832 |
| Bipolar | 0.83 (0.63-1.09) | .173 | 0.81 (0.62-1.06) | .122 |
| Schizophrenia | 0.51 (0.28-0.93) | .028 | 0.51 (0.28-0.92) | .028 |
Note. Multivariate logistic regression model included age, sex, Charlson Comorbidity Index, tobacco use, diabetes, antidepressant use, and osteoporosis. OR = odds ratio; CI = confidence interval.
Bold indicates statistical significance (P < .05).
Discussion
Through an analysis of a large, national database, this study demonstrated that patients with comorbid psychiatric diagnoses, such as depression, anxiety, bipolar disorder, and schizophrenia, experienced delayed scaphoid union at significantly increased rates. Similarly, in the combined cohort, these patients were more likely to undergo nonacute surgical stabilization or bone grafting to address their fracture. The influence of comorbid psychiatric conditions on the outcomes of orthopedic procedures has been well documented. In total joint arthroplasty, preoperative depression has been associated with worse general outcomes, increased rates of postoperative infections, increased length of hospital stay, and implant-related complications, such as periprosthetic fracture, revision TKA, and extensor mechanism rupture within 1 year of operation.10,12 -16 Klement et al 16 described that within 30 days of a TKA, a comorbid diagnosis of bipolar disorder, depression, or schizophrenia was associated with a 120% increase in rates of periprosthetic fracture, 34% increase in rates of osteolysis, 101% increase in rates of revision TKA, and 116% increase in rates of patellar complications. These complications result in significantly increased rates of postprocedural dissatisfaction, as well as increased costs to both the patient and the health care system.12,17
The intersection of psychiatric disease and orthopedic surgery is a well-studied, yet still evolving field.18 -21 Regarding hand pathology specifically, Vranceanu and Ring 19 described the value of emotional health assessments of patients before surgery to provide them the best level of care to maximize their functional outcomes after surgery. They also recommend clinician and psychologist collaboration for patients with comorbid psychiatric conditions such as depression to better address the emotional needs of these patients. 18 Beyond surgical outcomes, there is also literature that describes psychosocial factors as individual risk factors for extended sick leave following carpal tunnel release, as well as increased pain and poorer work status in these patients following upper extremity musculoskeletal pathology.22,23 Better emotional health has a direct correlation with better functional outcomes following upper extremity surgery. Clinically, these patients can be identified preoperatively and can be placed on a different postoperative path to maximize their functional outcomes. 24
Comorbid psychiatric conditions have also been linked to impaired wound healing. Proper wound healing is critical in the recovery of any injury or surgical process, and dysfunctional wound healing can delay the return to normal activities of daily living, increase rates of infection, and increase patient dissatisfaction. 25 In a systematic review, Walburn et al 26 found the impact of psychological stress on wound healing to be as significant as other accepted risk factors such as advanced age, diabetes, and nutritional deficiencies. This phenomenon is believed to be the result of chronic activation of both the hypothalamic-pituitary-adrenal and the sympathetic-adrenal-medullary axes, leading to chronically elevated levels of catecholamines and glucocorticoids that influence various aspects of the healing process. 27 Similarly, high levels of anger expression have also been associated with delayed wound healing, demonstrating the complex impact of psychological stress on proper wound healing. 28
This study specifically demonstrated the association of psychiatric comorbidities such as depression, anxiety, bipolar disorder, and schizophrenia with the rates of delayed fracture union. While less researched than superficial wound healing, a recent study published by Nie et al 29 described the effect of depression on fracture healing in a rat model. They reported that rats with depressive disorder had significantly decreased fracture healing at 4 and 8 weeks after injury. The osteogenic potential of bone marrow mesenchymal stem cells harvested from the rats with depression was markedly decreased, which led to decreased osteoblast differentiation and slower fracture healing. 29 Possibly through a similar mechanism, chronic depression has been associated with poor BMD in several epidemiological studies and meta-analyses.30 -32
Although this study controlled for osteoporosis in the multivariate logistic regression model, the remaining significant difference in the rates of delayed scaphoid may be partially explained by the prevalence of underdiagnosed osteoporosis. 33 Osteoporosis is characterized by a systemic decrease in BMD and bone strength and is highly associated with delayed fracture union and even increased nonunion rates.34,35 Despite the prevalence of osteoporosis, diagnosing osteoporosis requires a high level of suspicion and is often only made after a fragility fracture. Even with sufficient evidence to make a diagnosis of osteoporosis, less than 20% of patients had mention of low BMD in their medical records. 36 In this context, cases of undiagnosed or uncoded low BMD may potentially affect the results of this study.
While there was a difference in the rates of delayed scaphoid union seen in the overall cohorts, the difference was most apparent in female-specific analyses. Women with comorbid psychiatric disorders were 58% and 48% more likely to experience delayed scaphoid union at 3 and 6 months, respectively, compared with control, whereas in men, there was largely no difference compared with control. In women with depression specifically, the rate at the 3-month mark increased to 68%, whereas in men, there was still no significant difference. One explanation for the sex-specific differences in the rates of delayed scaphoid union is the underdiagnosis of osteoporosis in women.33,37 Women are more prone to developing osteoporosis compared with men, so they likely represent a larger portion of the cases of undiagnosed osteoporosis.33,37 A second explanation is the worsening of depressive symptoms in female patients compared with men. Salk et al 38 performed a meta-analysis of sex differences in depression and reported that not only are women diagnosed with depression earlier in life and more often than men, but they also experience increased severity of depressive symptoms. Speculatively, when viewed in conjunction with the existing research describing the impact of chronic stress and depression on BMD and fracture healing, the severity of depression may influence the degree of slowed fracture healing and loss of BMD.
As psychiatric diagnoses are becoming more common, it is important to recognize their complexity and the impact that these conditions have on other aspects of a patient’s health care. 39 Many of these psychiatric conditions present in conjunction with one another. As a result, all physicians, including orthopedists treating hand and wrist fractures, need to have a good understanding of how they present to identify patients who may be at increased risk of dysfunctional wound or fracture healing and other potential complications. 40
As with other retrospective database studies, this study has several limitations. While PearlDiver contains health records of more than 150 million patients, this is not a random sample and only includes insured individuals and is therefore subjected to sampling bias. This study also depended on ICD and CPT billing codes to isolate specific diagnoses and procedures. As a result, there is the possibility of miscoding. However, as the sample size was large, we believe this limitation to have little impact on the overall results of the study. Finally, by the nature of the data set, we were unable to assess the severity and location of the initial fracture. These factors are known to influence fracture healing. To limit the impact of this limitation, fractures initially managed with surgery that were inherently more complex and had the greatest risk of delayed union were excluded from the study. Only those that began with nonoperative management were included in the analysis.
Conclusion
Patients with comorbid psychiatric diagnoses, most notably depression, anxiety, and schizophrenia, experienced an increased rate of delayed scaphoid fracture union at 3 and 6 months from the initial fracture. Sex-specific and psychiatric diagnosis–specific differences in rates of delayed union were observed, with women with depression and schizophrenia being the most-at-risk groups. In addition, patients with comorbid psychiatric diagnoses were more likely to undergo nonacute surgical intervention to address their delayed scaphoid healing. These results underscore the importance for orthopedic surgeons to understand factors that may place patients at increased risk of impaired recovery.
Supplemental Material
Supplemental material, sj-docx-1-han-10.1177_15589447221142894 for Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients by J. Alex Albright, Elliott Rebello, Kenny Chang, Edward J. Testa, Alan H. Daniels and Julia A. Katarincic in HAND
Supplemental material, sj-docx-2-han-10.1177_15589447221142894 for Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients by J. Alex Albright, Elliott Rebello, Kenny Chang, Edward J. Testa, Alan H. Daniels and Julia A. Katarincic in HAND
Footnotes
Ethical Approval: This study did not require review by our institutional review board.
Statement of Human and Animal Rights: There were no violations of human or animal rights throughout the duration of the work conducted for this study.
Statement of Informed Consent: This study used a de-identified data set and did not require patient informed consent.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JAA, ER, KC, EJT, and JAK do not report any disclosures. AHD reports disclosures as follows: EOS, paid consultant; Orthofix, Inc., paid consultant, research support; SpineArt, paid consultant; Medtronic/Medicrea, paid consultant; Springer: publishing royalties, financial or material support; Stryker: paid consultant, all outside submitted work.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: J. Alex Albright 
https://orcid.org/0000-0001-9579-9924
Edward J. Testa
https://orcid.org/0000-0002-8693-1396
Supplemental material is available in the online version of the article.
References
- 1. Alshryda S, Shah A, Odak S, et al. Acute fractures of the scaphoid bone: systematic review and meta-analysis. Surgeon. 2012;10(4):218-229. doi: 10.1016/j.surge.2012.03.004. [DOI] [PubMed] [Google Scholar]
- 2. Pinder RM, Brkljac M, Rix L, et al. Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am. 2015;40(9):1797-1805.e3. doi: 10.1016/j.jhsa.2015.05.003. [DOI] [PubMed] [Google Scholar]
- 3. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br. 1989;71(2):307-310. [DOI] [PubMed] [Google Scholar]
- 4. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Jt Surg. 1972;58(8):1612-1632. [PubMed] [Google Scholar]
- 5. Seeman E, Melton LJ, O’Fallon WM, et al. Risk factors for spinal osteoporosis in men. Am J Med. 1983;75(6):977-983. doi: 10.1016/0002-9343(83)90878-1. [DOI] [PubMed] [Google Scholar]
- 6. Wickham CA, Walsh K, Cooper C, et al. Dietary calcium, physical activity, and risk of hip fracture: a prospective study. BMJ. 1989;299(6704):889-892. doi: 10.1136/bmj.299.6704.889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Pocock NA, Eisman JA, Kelly PJ, et al. Effects of tobacco use on axial and appendicular bone mineral density. Bone. 1989;10(5):329-331. doi: 10.1016/8756-3282(89)90128-2. [DOI] [PubMed] [Google Scholar]
- 8. Jensen J, Christiansen C, Rødbro P. Cigarette smoking, serum estrogens, and bone loss during hormone-replacement therapy early after menopause. N Engl J Med. 1985;313(16):973-975. doi: 10.1056/NEJM198510173131602. [DOI] [PubMed] [Google Scholar]
- 9. Murray R. The Role of Smoking in the Progressive Decline of the Body’s Major Systems. London, England: Public Health England; 2014. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/774658/The_role_of_smoking_in_the_progressive_decline_of_the_bodys_major_systems.pdf. Accessed January 19, 2022. [Google Scholar]
- 10. Vakharia RM, Ehiorobo JO, Sodhi N, et al. Effects of depressive disorders on patients undergoing primary total knee arthroplasty: a matched-control analysis. J Arthroplasty. 2020;35(5):1247-1251. doi: 10.1016/j.arth.2019.12.011. [DOI] [PubMed] [Google Scholar]
- 11. Freshman RD, Salesky M, Cogan CJ, et al. Association between comorbid depression and rates of postoperative complications, readmissions, and revision arthroscopic procedures after elective hip arthroscopy. Orthop J Sports Med. 2021;9(9):23259671211036493. doi: 10.1177/23259671211036493. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Pan X, Wang J, Lin Z, et al. Depression and anxiety are risk factors for postoperative pain-related symptoms and complications in patients undergoing primary total knee arthroplasty in the United States. J Arthroplasty. 2019;34(10):2337-2346. doi: 10.1016/j.arth.2019.05.035. [DOI] [PubMed] [Google Scholar]
- 13. Vajapey SP, McKeon JF, Krueger CA, et al. Outcomes of total joint arthroplasty in patients with depression: a systematic review. J Clin Orthop Trauma. 2021;18:187-198. doi: 10.1016/j.jcot.2021.04.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Götz JS, Benditz A, Reinhard J, et al. Influence of anxiety/depression, age, gender and ASA on 1-year follow-up outcomes following total hip and knee arthroplasty in 5447 patients. J Clin Med. 2021;10(14):3095. doi: 10.3390/jcm10143095. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Browne JA, Sandberg BF, D’Apuzzo MR, et al. Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. J Arthroplasty. 2014;29(3):481-483. doi: 10.1016/j.arth.2013.08.025. [DOI] [PubMed] [Google Scholar]
- 16. Klement MR, Nickel BT, Penrose CT, et al. Psychiatric disorders increase complication rate after primary total knee arthroplasty. Knee. 2016;23(5):883-886. doi: 10.1016/j.knee.2016.05.007. [DOI] [PubMed] [Google Scholar]
- 17. Menendez ME, Neuhaus V, Bot AG, et al. Do psychiatric comorbidities influence inpatient death, adverse events, and discharge after lower extremity fractures? Clin Orthop Relat Res. 2013;471(10):3336-3348. doi: 10.1007/s11999-013-3138-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Ring D, Barth R, Barsky A. Evidence-based medicine: disproportionate pain and disability. J Hand Surg Am. 2010;35(8):1345-1347. doi: 10.1016/j.jhsa.2010.06.007. [DOI] [PubMed] [Google Scholar]
- 19. Vranceanu AM, Ring D. Value of psychological evaluation of the hand surgical patient. J Hand Surg Am. 2008;33(6):985-987. doi: 10.1016/j.jhsa.2008.05.007. [DOI] [PubMed] [Google Scholar]
- 20. Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35(6):956-960. doi: 10.1016/j.jhsa.2010.02.001. [DOI] [PubMed] [Google Scholar]
- 21. Lozano Calderón SA, Paiva A, Ring D. Patient satisfaction after open carpal tunnel release correlates with depression. J Hand Surg Am. 2008;33(3):303-307. doi: 10.1016/j.jhsa.2007.11.025. [DOI] [PubMed] [Google Scholar]
- 22. Hansen TB, Dalsgaard J, Meldgaard A, et al. A prospective study of prognostic factors for duration of sick leave after endoscopic carpal tunnel release. BMC Musculoskelet Disord. 2009;10(1):144. doi: 10.1186/1471-2474-10-144. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Harrington CB, Siddiqui A, Feuerstein M. Workstyle as a predictor of pain and restricted work associated with upper extremity disorders: a prospective study. J Hand Surg Am. 2009;34(4):724-731. doi: 10.1016/j.jhsa.2008.12.012. [DOI] [PubMed] [Google Scholar]
- 24. Ayers DC, Franklin PD, Ring DC. The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues. J Bone Jt Surg. 2013;95(21):e165. doi: 10.2106/JBJS.L.00799. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Brown J. The impact of stress on acute wound healing. Br J Community Nurs. 2016;21(suppl 12):S16-S22. doi: 10.12968/bjcn.2016.21.Sup12.S16. [DOI] [PubMed] [Google Scholar]
- 26. Walburn J, Vedhara K, Hankins M, et al. Psychological stress and wound healing in humans: a systematic review and meta-analysis. J Psychosom Res. 2009;67(3):253-271. doi: 10.1016/j.jpsychores.2009.04.002. [DOI] [PubMed] [Google Scholar]
- 27. Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am. 2011;31(1):81-93. doi: 10.1016/j.iac.2010.09.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Gouin JP, Kiecolt-Glaser JK, Malarkey WB, et al. The influence of anger expression on wound healing. Brain Behav Immun. 2008;22(5):699-708. doi: 10.1016/j.bbi.2007.10.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Nie C, Wang Z, Liu X. The effect of depression on fracture healing and osteoblast differentiation in rats. Neuropsychiatr Dis Treat. 2018;14:1705-1713. doi: 10.2147/NDT.S168653. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Rosenblat JD, Gregory JM, Carvalho AF, et al. Depression and disturbed bone metabolism: a narrative review of the epidemiological findings and postulated mechanisms. Curr Mol Med. 2016;16(2):165-178. doi: 10.2174/1566524016666160126144303. [DOI] [PubMed] [Google Scholar]
- 31. Wu Q, Magnus JH, Liu J, et al. Depression and low bone mineral density: a meta-analysis of epidemiologic studies. Osteoporos Int. 2009;20(8):1309-1320. doi: 10.1007/s00198-009-0918-x. [DOI] [PubMed] [Google Scholar]
- 32. Lee CWS, Liao CH, Lin CL, et al. Increased risk of osteoporosis in patients with depression. Mayo Clin Proc. 2015;90(1):63-70. doi: 10.1016/j.mayocp.2014.11.009. [DOI] [PubMed] [Google Scholar]
- 33. Nguyen TV, Center JR, Eisman JA. Osteoporosis: underrated, underdiagnosed and undertreated. Med J Aust. 2004;180(suppl 5):S18-S22. doi: 10.5694/j.1326-5377.2004.tb05908.x. [DOI] [PubMed] [Google Scholar]
- 34. Coughlan T, Dockery F. Osteoporosis and fracture risk in older people. Clin Med. 2014;14(2):187-191. doi: 10.7861/clinmedicine.14-2-187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014;29(11):2520-2526. doi: 10.1002/jbmr.2269. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Gehlbach SH, Fournier M, Bigelow C. Recognition of osteoporosis by primary care physicians. Am J Public Health. 2002;92(2):271-273. doi: 10.2105/AJPH.92.2.271. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Lane NE. Epidemiology, etiology, and diagnosis of osteoporosis. Am J Obstet Gynecol. 2006;194(2):S3-S11. doi: 10.1016/j.ajog.2005.08.047. [DOI] [PubMed] [Google Scholar]
- 38. Salk RH, Hyde JS, Abramson LY. Gender differences in depression in representative national samples: meta-analyses of diagnoses and symptoms. Psychol Bull. 2017;143(8):783-822. doi: 10.1037/bul0000102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39. Krystal JH, State MW. Psychiatric disorders: diagnosis to therapy. Cell. 2014;157(1):201-214. doi: 10.1016/j.cell.2014.02.042. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Gorman JM. Comorbid depression and anxiety spectrum disorders. Depress Anxiety. 1996;4(4):160-168. doi: 10.1002/(SICI)1520-6394(1996)4:4<160::AID-DA2>3.0.CO;2-J. [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Supplemental material, sj-docx-1-han-10.1177_15589447221142894 for Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients by J. Alex Albright, Elliott Rebello, Kenny Chang, Edward J. Testa, Alan H. Daniels and Julia A. Katarincic in HAND
Supplemental material, sj-docx-2-han-10.1177_15589447221142894 for Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients by J. Alex Albright, Elliott Rebello, Kenny Chang, Edward J. Testa, Alan H. Daniels and Julia A. Katarincic in HAND