Changes in mental health and joint-specific patient-reported outcome measures following arthroscopic shoulder labral repair

Abstract

Background

The purpose was to identify the effects of mental health on postoperative outcomes following arthroscopic labral repair. It was hypothesized that low preoperative mental health, measured by the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS), would demonstrate inferior patient-reported outcome measures preoperatively and postoperatively, but that improvement would be similar.

Methods

Fifty subjects undergoing a primary arthroscopic anterior labral repair were included. Subjects completed the VR-12 MCS, Pain Visual Analog Scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) at 4 timepoints. Subjects with a VR-12 MCS score below 42.9 were classified to a low MCS cohort and those with a VR-12 MCS score above 42.9 were cataloged to a high MCS group. Patient-reported outcome measures were compared between the 2 groups.

Results

At mean follow-up of 18.7 months, ASES (P < .001), VAS (low MCS P = .004; high MCS P < .001), and SANE (P < .001) scores significantly improved for both cohorts. The low MCS group had significantly lower ASES scores at both points (P = .01); however, the preoperative to postoperative change in ASES (P = .32) did not differ. VR-12 MCS scores remained constant in the high MCS cohort but significantly improved for the low MCS cohort (P = .01).

Conclusion

Patients in the low VR-12 MCS group had lower postoperative outcomes but demonstrated similar preoperative to postoperative improvements in ASES, SANE, and VAS to those in the high group. VR-12 MCS significantly improved for the low MCS group suggesting that low preoperative mental health scores should not be considered a contraindication for surgery and mental health scores are modifiable.

Shoulder instability has an incidence of 23.9 per 100,000 persons and is 2.6% more common in males than in females.²⁵ Risk factors of traumatic shoulder instability include being young, male, a contact sport athlete, and prior dislocations.¹⁵ The most common treatment for traumatic shoulder instability in a first-time dislocator or after failure of nonoperative management is an arthroscopic labral repair. Studies that investigate the relationship between musculoskeletal injuries and clinical depression show that worse preoperative psychosocial factors have demonstrated worse postoperative outcome scores.⁴ Another study found that after shoulder stabilization, in both the categorized depressed and nondepressed groups, there was an improvement of both function and depression symptoms. However, the depression cohort continued to have worse shoulder and depression outcomes 1 year postoperation.²²

According to the World Health Organization, depression and anxiety are some of the leading causes of disabilities globally.²⁴ The incidence of depression in college athletes has been estimated to be as low as 15.9% and as high as 23.7%.^17,23 It has also been demonstrated that injured athletes report increased depressive symptoms when compared to uninjured athletes.⁶ Depression has been found to be a profound predictor of chronic postsurgical pain as the negative effects of depression as well as poor mental health impact postoperative healing.¹⁰ Investigating the relationship between a patients' mental health status and shoulder functionality following surgical stabilization could encourage physicians to take initiative and modify these risks preoperatively, ultimately leading to improved outcomes.

The purpose of this study was to determine if postoperative outcomes differ between those with a greater degree of emotional distress prior to arthroscopic labral repair. The authors hypothesized that patients with low preoperative mental health, as measured by the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS), would demonstrate (1) significant improvements in MCS scores after surgery and (2) inferior patient-reported outcomes both prior to and following surgery, but that the relative improvements would be similar between the 2 groups.

Methods

Data collection

Approval by the institutional review board was obtained prior to initiation of the study (IRB #2011P002663). Inclusion criteria included patients aged more than 18 years, undergoing a primary arthroscopic anterior labral repair to treat instability from a single surgeon (E. G. M.) in a single academic medical center. These patients were prospectively collected from July 2017 to May 2023. Seventy seven patients who met inclusion criteria were enrolled in this study and retrospectively reviewed. Exclusion criteria included patients with posterior or multidirectional instability, those undergoing a revision procedure, having concomitant surgical procedures including rotator cuff repair and biceps tenodesis, possessing co-existing lesions, experiencing additional surgical procedures, and patients with incomplete preoperative and postoperative patient-reported outcome data. This resulted in a total cohort of 50 patients.

All subjects received a voluntary survey through the Surgical Outcome System (SOS; Arthrex, Naples, Florida, USA) patient-reported outcome platform at 4 timepoints: preoperatively and 6, 12, and 24 months postoperatively. This survey consisted of the following outcome measuring tools: (1) the Pain Visual Analog Scale (VAS) score, ranging from 0 to 10 and used to measure overall pain level; (2) the VR-12 MCS, a self-reported comprehensive questionnaire used to evaluate a patient's interpretation of their own well-being;¹² (3) the American Shoulder and Elbow Surgeons (ASES) score, a 10-item questionnaire that assesses function limitations and shoulder pain in patients;¹⁹ and (4) the Single Assessment Numeric Evaluation (SANE), a single-item measure that allows patients to self-report how normal they feel in relation to their injury.⁸ At the time of surgical consent, patients were consented by the surgeon or the research assistant (E. G. M. or N. L.).

Surgery and postoperative management

All patients underwent an outpatient primary arthroscopic anterior labral repair using a preoperative scalene block as well as general anesthesia. This was a standard scalene block performed in the preoperative holding area under ultrasound guidance by the anesthesia team. All surgeries were performed arthroscopically in a lateral decubitus position with knotless anchors. Patients were discharged home with a cryotherapy unit and a sling for 4-6 weeks, and all followed the senior surgeon’s standard labral repair rehabilitation protocol which persists for approximately 5 months. Patients are instructed to use a sling for up to 6 weeks postoperatively to protect their repair. When they are home, at a desk, and are in a controlled environment, they are allowed to remove the sling.

Statistical analysis

Consistent with prior work, patients were categorized into low and high groups based on whether their preoperative VR-12 MCS scores were above or below 42.9.¹³ This score represents the threshold for the bottom quartile of the US population.²⁰ Subjects who had a VR-12 MCS score below (<) 42.9 were classified as members of the low MCS group and those who had a VR-12 MCS score above (>) 42.9 were classified as members of the high MCS group. Demographic factors and baseline characteristics were compared between low and high MCS groups using 2-tailed, independent t-tests or Fisher’s exact tests as appropriate. Using the results from the patient's most recent follow-up, preoperative and postoperative ASES, SANE, Pain VAS, and VR-12 MCS scores were compared between groups using 2 × 2 mixed model analysis of variance tests. Bonferroni post hoc analyses were used to identify the location of paired differences. The number of patients in the low and high MCS groups that achieved previously reported minimal clinically important differences (MCIDs) were compared using Fisher’s exact tests. The MCID thresholds for patients with shoulder instability were 1.7 for the Pain VAS, 8.5 for the ASES score, and 12.4 for the SANE score.¹⁶ All analyses were performed with SPSS Statistics version 29 (IBM Corp., Armonk, NY, USA).

Results

Seventy seven patients, undergoing a primary arthroscopic anterior labral repair to treat instability, who were aged more than 18 years, had no history of repair on the indexed shoulder, and had complete preoperative and postoperative patient-reported outcome data were prospectively enrolled in the study. Twenty seven subjects were subsequently excluded as they were lacking either a preoperative or postoperative VR-12 MCS score, resulting in a study cohort of 50 subjects. Descriptive baseline demographics and clinical characteristics are described in Table I. This study cohort included 12 females (24%) and 38 males (76%) with a mean age of 31.0 ± 15.2 years, a mean body mass index (BMI) of 26.5 ± 4.7 kg/m², and mean follow-up of 18.7 months.

Table I.

Description of cohort.

Variable	n (%) or mean ± standard deviation
Sex
Female	12 (24%)
Male	38 (76%)
Age	31.0 ± 15.2
BMI (kg/m2)	26.5 ± 4.7
Race
Asian	3 (6%)
Asian, Native Hawaiian, or Other Pacific Islander	1 (2%)
White	44 (88%)
Black	2 (4%)
Ethnicity
Hispanic or Latino	2 (4%)
Not Hispanic or Latino	47 (96%)
Workers’ compensation case
Yes	2 (4%)
No	48 (96%)

N, sample size; BMI, body mass index.

Baseline demographics.

Ten subjects (20%) were categorized as part of the low MCS group, and 40 subjects (80%) comprised the high MCS group. Those in the low MCS group included 3 (30%) female subjects and 7 (70%) male subjects with an average age of 37.0 ± 17.4 years, an average BMI of 26.0 ± 5.0 kg/m², and 3 (30%) subjects reporting a positive smoking status (Table II). Subjects in the high MCS group included 9 (22.5.%) female subjects and 31 (77.5%) male subjects with an average age of 29.5 ± 14.9 years, an average BMI of 26.6 ± 4.6 kg/m², and 1 (3%) patient reporting a positive smoking status (Table II). There were no significant differences in age, sex, BMI, or workers’ compensation claims between the low and high MCS group. A significantly greater proportion of the low MCS group self-reported a positive smoking status (P = .02; Table II).

Table II.

Comparison of demographic and baseline characteristics between those with low vs. high preoperative VR-12 MCS scores.

	Low MCS	High MCS	P value
N	10	40
Age	37.0 ± 17.4	29.5 ± 14.9	.17
Female sex	3 (30%)	9 (22.5%)	.69
BMI	26.0 ± 5.0	26.6 ± 4.6	.71
Smoker	3 (30%)	1 (3%)	.02
Workers’ compensation	0	2	>.99

VR-12 MCS, Veterans RAND 12-Item Health Survey Mental Component Score; N, sample size; BMI, body mass index.

Values are represented as mean ± standard deviation or number (%).

As would be expected, patients categorized into the low MCS group demonstrated significantly lower preoperative VR-12 MCS scores prior to surgery than those in the high group (35.8 ± 4.7 vs. 56.0 ± 6.0; P < .001; Table III). However, while VR-12 MCS scores remained constant after surgery for the high group (preoperative = 56.0 ± 6.0; postoperative = 55.9 ± 8.7; P = .92), the low MCS group demonstrated a significantly greater preoperative to postoperative change in VR-12 MCS scores (preoperative = 35.8 ± 4.7; postoperative = 46.5 ± 12.0; P = .01; Fig. 1, A; Table III). In fact, 6 of the 10 patients in the low MCS group no longer had scores below the 42.9-point threshold after surgery (Table III).

Table III.

Comparison of preoperative and postoperative patient-reported outcome scores between patients with low vs. high preoperative MCS scores.

	Low MCS	High MCS	P value (between groups)
VR-12 MCS			<.001
Preoperative	35.8 ± 4.7	56.0 ± 6.0
Postoperative	46.5 ± 12.0	55.9 ± 8.7
P value (over time)	.01	.92
ASES			.01
Preoperative	49.9 ± 27.2	67.8 ± 16.7
Postoperative	78.6 ± 23.8	90.0 ± 14.2
P value (over time)	<.001	<.001
SANE			.10
Preoperative	30.9 ± 21.7	41.0 ± 18.5
Postoperative	72.3 ± 22.2	80.0 ± 21.6
P value (over time)	<.001	<.001
Pain VAS			.07
Preoperative	4.8 ± 3.0	2.8 ± 2.3
Postoperative	1.4 ± 1.6	1.0 ± 1.8
P value (over time)	.004	<.001

VR-12 MCS, Veterans RAND 12-Item Health Survey Mental Component Score; ASES, American Shoulder and Elbow Surgeons; SANE, Single Assessment Numeric Evaluation; VAS, visual analog scale.

Values are represented as mean ± standard deviation or number (%).

Figure 1.

Preoperative and postoperative patient-reported outcomes for patients with low vs. high VR-12 MCS scores. (A) VR-12 MCS, (B) ASES, (C) Pain VAS, and (D) SANE. VR-12 MCS, Veterans RAND 12-Item Health Survey Mental Component Score; ASES, American Shoulder and Elbow Surgeons; VAS, visual analog scale; SANE, Single Assessment Numeric Evaluation.

ASES scores significantly improved for both the low and high MCS groups (P < .001; Table III). The low MCS group had significantly lower ASES scores both prior to and following surgery (low MCS preoperatively = 49.9 ± 27.2, postoperative = 78.6 ± 23.8; high MCS preoperatively = 67.8 ± 16.7, postoperative = 90.0 ± 14.2; P = .01; Table III) compared to the high MCS group. However, the preoperative to postoperative change in ASES scores did not differ between groups (P = .32; Fig. 1, B).

Similarly, Pain VAS scores significantly improved after surgery for both the low and high MCS groups (low MCS P = .004; high MCS P < .001). Pain VAS scores tended to be higher for the low MCS group at both timepoints (low MCS preoperatively = 4.8 ± 3.0, postoperative = 1.4 ± 1.6; high MCS preoperatively = 2.8 ± 2.3, postoperative = 1.0 ± 1.8; P = .07; Table III), although the preoperative to postoperative improvement in Pain VAS tended to be greater for those in the low MCS group (P = .051; Fig. 1, C). Finally, SANE scores significantly improved for both the low and high MCS groups (P < .001; Table III), with the low MCS group tending to have lower SANE scores prior to and following surgery compared to the high MCS group (low MCS preoperatively = 30.9 ± 21.7, postoperative = 72.3 ± 22.2; high MCS preoperatively = 41.0 ± 18.5, postoperative = 80.0 ± 21.6; P = .10; Fig. 1, D).

While the relatively small number of patients in the low MCS group may limit interpretability, it was interesting to note that the number of patients that achieved MCID improvements after surgery did not differ between groups (ASES: Low 9/10 [90%], High 29/39 [74.4%], P = .42; SANE: Low 9/10 [90%], High 34/39 [87.2%], P > .99; Pain VAS: Low 7/10 [70%], High 18/40 [45%], P = .29).

Discussion

The main findings of this study were that while patients with low preoperative VR-12 MCS scores had lower postoperative patient-reported outcome scores when compared to those with higher preoperative MCS scores, VR-12 MCS scores significantly improved for the low group. The low group also demonstrated similar preoperative to postoperative improvements in ASES, SANE, and Pain VAS as the high group. These findings are clinically relevant as they suggest that (1) low preoperative mental health scores should not be considered a contraindication for surgery and (2) mental health scores are modifiable thereby providing a potential target for perioperative interventions. These results align with previous results of significant decreases in psychological healthcare utilization following rotator cuff repair and hip arthroscopy for patients with preoperative diagnoses of depression or anxiety.^1,26 Gowd et al also reported significant improvements in VR-12 MCS scores after rotator cuff repair, and that preoperative MCS scores were predictive of a patient's ability to return to work.⁵

The improved VR-12 MCS scores in the present study point toward potential neuroplastic changes when shoulder instability is successfully corrected. Multiple studies have demonstrated that patients with shoulder apprehension or shoulder instability demonstrate altered neural activation patterns in the brain.^3,11,28 These altered neural activation patterns are also linked to negative mood, fear, and anxiety, and may be the connection between instability and reduced preoperative mental health scores for this subset of patients.^7,21 However, when joint stability is restored, neural activation patterns change after surgery, with decreased activity in premotor and orbito-frontal cortex being associated with improved clinical outcomes.²⁷

Additionally, significant postoperative improvements in ASES, SANE, and Pain VAS outcomes were observed for both the low MCS group and the high MCS group. While both preoperative and postoperative scores were generally lower for the low MCS group, the magnitude of preoperative to postoperative changes in outcome scores did not significantly differ among groups. Thus, these results support the hypothesis that patients with lower preoperative mental health scores would demonstrate lower patient-reported outcomes at both baseline and postoperative timepoints, but that both groups would demonstrate significant improvement. These findings parallel Hines et al who conducted a study analyzing patients undergoing arthroscopic rotator cuff repair. The authors concluded that patients with lower ASES outcomes, as measured by scores that did not meet the defined Substantial Clinical Benefit threshold, exhibited lower VR-12 MCS scores at baseline and at the 6-month postoperative timepoint when compared to a cohort of patients with ASES scores that met the Substantial Clinical Benefit threshold.⁹ Similarly, Kim et al published a review that examined patients undergoing an arthroscopic Bankart repair, specifically examining the return to sport rate and the associated reasons for failure. The review established that 15.6% of the studied patient population failed to return to sport and the failure of 43.3% of this cohort could be contributed to reasons independent of the physical capacity of the indicated shoulder.¹⁴ The most common of these reasons included the psychological factor of fear of reinjury. The results from Hines et al and Kim et al further emphasize the clinical relevance that can be drawn from this study which highlights the importance of assessing mental health factors in addition to the physical components when developing treatment plans with patients with shoulder instability. Further research and investigation into preoperative mental health screening and the impact of psychological intervention on postoperative outcomes needs to be performed to further understand the effect on outcomes.

Finally, in this study, a preoperative positive smoking status is associated with low MCS scores. However, this result is to be approached with caution as the sample size of patients who self-reported a positive smoking status was 4 with 3 of those total patients meeting the criteria for the low MCS group. However, this finding can be supported by Cefalu et al which used a cohort of patients undergoing an arthroscopic rotator cuff repair and stratified these patients based on smoking status. The study revealed that patients who reported a positive smoking status had lower preoperative VR-12 MCS scores and lower functional outcomes postoperatively when compared to patients who did not smoke.² Both Cefalu et al and the present study's findings suggest that this correlation may be clinically relevant as patients who smoke may be disadvantaged from a mental health perspective which may lead to worse outcomes postoperatively. In the future, it may benefit both the surgeon and the patient to account for this when formulating a treatment plan.

Limitations

Limitations of this study include the small cohort of patients from a single surgeon at a single academic institution. A prior power analysis was not performed so this represents a sample of convenience identified from our prospective surgical outcomes registry. While the study was informative about the relationship between mental health and postoperative outcomes, only the VR-12 MCS was used. Other psychological factors, social determinants of health, and medical comorbidities were not considered when collecting or analyzing the data. Additionally, we did not capture other factors that could contribute to low preoperative mental health score such as pain chronicity, severe apprehension, the number of instability events, or bone loss. Furthermore, a lack of shoulder instability–specific scores and a small sample size is a limitation of this study. Finally, psychosocial factors such as fear of reinjury¹⁸ or smoking status can also worsen postoperative outcomes. The low MCS group had significantly more patients who smoked tobacco products than the high MCS group. It is possible that these variables could have confounded the relationship between categorical depression and functional status postoperatively.

Conclusion

While patients with low preoperative VR-12 MCS scores generally had lower postoperative patient-reported outcome scores when compared to those with higher preoperative MCS scores, those with low preoperative VR-12 MCS scores demonstrated similar preoperative to postoperative improvements in ASES, SANE, and Pain VAS scores to those in the high group. Importantly, VR-12 MCS scores significantly improved after surgery for the low MCS group. These findings suggest that low preoperative mental health scores should not be considered a contraindication for surgery, and mental health scores are modifiable, thereby providing a potential target for perioperative interventions.

Disclaimers

Funding: No funding was disclosed by the authors.

Conflicts of interest: Dr. Elizabeth G. Matzkin receives consultant payments from Arthrex. All authors, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.