The Effect of Depression on Patient Reported Outcomes Measurement and Information System Computer Adaptive Test (PROMIS-CAT) scores and Return-to-Sport following ACL Reconstruction
Authors: Kuhns Benjamin , Reuter John , Rouse Lucien , Goldblatt John , Bronstein Robert , Maloney Michael , Baumhauer Judith , Mannava Sandeep , Schaffer Joseph 
Published: July 2020

Objectives:

Depression has been shown to have a negative effect on many orthopaedic surgical outcomes. The purpose of this study was to determine whether preoperative clinical diagnosis of depression and/or PROMIS (Patient-Reported Outcomes Measurement Information System) Depression scores predicted worse postoperative therapy compliance, functional outcomes, and return-to-sport after anterior cruciate ligament (ACL) reconstruction.

Methods:

A multi-surgeon series of consecutive patients who had undergone ACL reconstruction at a single institution between 1/4/16 and 7/19/16 were evaluated for inclusion. Patients who had completed preoperative PROMIS Depression (D), Physical Function (PF), and Pain Interference (PI) questionnaires were prospectively enrolled to complete minimum 2-year follow-up PROMIS and Return-to-Sport (ACL-RSI short-form) questionnaires. Chart review was conducted to determine depression diagnosis status, demographic data, and rehabilitation physical therapy (PT) compliance. PROMIS D score cutoff for mild depression was >52.5, based on previously established correlation to the validated Patient Health Questionnaire-9.

Results:

Ninety-five of 115 consecutive patients (81%) met inclusion criteria. Average follow-up was 34+/-1.9 months. Fourteen patients (15%) carried a clinical diagnosis of depression. Thirty-two (34%) had a preoperative PROMIS D score above the mild depression threshold; of those, 2 (2%) scored in the moderate depression range, and 3 (3%) scored in the severe depression range. Overall, the cohort (including depressed patients) showed improvement in PROMIS PF and PI scores postoperatively (p<0.001) (Table 1). Diagnosed depressed patients had a higher rate of PT non-compliance (30.8%±17.3% vs. 21.9%±12.6%; p=0.04) and lower postoperative physical function (50.8±7.7vs. 57.5±10.5; p=0.03), but no differences in post-operative PROMIS PI (50.8±6.9vs. 46.7±6.8; p=0.32), compared to patients without depression diagnosis. The percentage of missed therapy appointments showed a correlation with lower postoperative PROMIS PF scores (r=0.33, p=0.008) in our cohort. PROMIS depressed (PROMIS D>52.5) and undiagnosed depression patients (subgroup of preoperative PROMIS depressed without depression diagnosis) showed no difference in PT compliance or postoperative PROMIS PF or PI, compared to non-depressed patients (Table 2). Undiagnosed preoperative depressed patients (n=21/95 (22%)) also showed improvement in their depression scores postoperatively (mean PROMIS D = 57.4±5.0 preop vs. 44.5±6.6 postop; p<0.0001) (Figure 1) and 19/21 (90.5%) patients in this group showed resolution in their personal PROMIS D score to non-depressed range (p=.001). PROMIS depressed patients were less likely to participate in a sport (16/32 (50.0%) vs. 50/63 (79.3%); p=0.003), but PROMIS depressed athletes had no differences in return to sport rates (10/16 (63%) vs. 25/50 (50%); p=0.38) or responses to the ACL-RSI Short Form questionnaire (p>0.05 for all).

Conclusion:

Clinically diagnosed depression is predictive of worse rehabilitation therapy compliance and worse functional outcomes after ACL reconstruction surgery, but even depressed patients can be expected to show improvement. PROMIS Depression scores, particularly in those without a clinical diagnosis of depression, can be expected to resolve to non-depressed range after ACL reconstruction. Patients with depressed mood preoperatively but no depression diagnosis could be considered to have “situational depression” and can be reassured that depression will likely resolve after ACL reconstruction. Patients with depression diagnosis, however, should be counseled regarding tempered expectations after ACL reconstruction. Resources should be allocated to incorporate behavioral health counseling pre- and post-surgery in an attempt to maximize outcomes.