Abstract
Objectives:
Medial patellofemoral ligament (MPFL) reconstruction is commonly performed in patients with recurrent patellar dislocations and associated instability. However, though general outcomes and when to perform concomitant surgical procedures such as a tibial tubercle osteotomy (TTO) have been studied, there remains limited information on the effects of underlying mental health conditions on baseline and post-operative outcome measures. Given the rising prevalence and number of undiagnosed number of patients with mental health conditions such as major depressive disorder (MDD), recognition that patients with chronic, recurrent patellar dislocations who require MPFL reconstruction may be at risk for inferior post-operative outcomes if they also have a mental health disorder. The purpose of this study is to assess how mental health disorders such as MDD or unrecognized depression can affect pre- and post-operative outcomes in patients undergoing MPFL.
Methods:
A retrospective, IRB approved review of patients undergoing MPFL reconstruction from 2015 to 2023 was performed. Demographic data, presence of diagnosed mental health disorders, complications, and Patient Reported Outcomes Measurement Information Systems (PROMIS) scores related to their procedure were collected. Exclusion criteria included patients aged <10 or >75 years, or those with incomplete PROMIS data. Patients without a formal diagnosis of MDD, but with a pre-op PROMIS-Dep score greater than or equal to 52.5 were considered PROMIS-Depressed. Kruskal-Wallis and chi-squared tests were used to compare continuous and categorical cohort descriptive statistics respectively. Logistic and mixed-effects regression were used to investigate the association between PROMIS T-scores and mental health disorders while adjusting for confounding patient and surgical variables.
Results:
187 patients met inclusion criteria. Descriptives of cohort variables tabulated by formal mental health disorder assessment are shown in Table 1. Patients with a mental health disorder were more likely to have an underlying connective tissue disease and require longer follow-up (512 vs 713 days, p <0.05). The presence of a mental health disorder led to significantly worse pre-and post-operative PROMIS scores, however there were no differences in the change in PROMIS scores after surgery nor was there a difference in ability to achieve MCID. Relative to patients without any mental health disorder, MDD patients and those PROMIS-depressed reported significantly worse pre- and post-operative PROMIS scores, with those who were PROMIS- depressed particularly doing worse (Figure 1). However, there were no differences in the change in PROMIS scores after surgery (despite depressed and PROMIS-depressed patients having more room for improvement), nor was there a difference in odds of achieving MCID (Figure 2). Regression analysis showed an association between underlying mental health disorders or need for additional procedures and worse average PROMIS scores in all domains. This was also seen with PROMIS-depressed patients, however presence of connective tissue disorders led to worse PROMIS-PI scores in this patient population. In addition, the odds of a reported complication or need to have a contralateral MPFL procedure were higher in patients requiring TTO. Increased age was associated with worse PROMIS-PI and PF scores. Partial correlation of the odds of needing MPFL on the contralateral extremity weakly correlated with lower odds of PROMIS-PI MCID achievement.
Conclusions:
The most important finding in our study is that underlying mental health disorders do not affect odds of achieving MCID after undergoing MPFL, however they do lead to worse pre- and post-operative PROMIS scores and prevented patients from deriving more improvement from their surgery. This finding was exacerbated in patients who were PROMIS-depressed. Overall, our cohort improved with surgery, but both diagnosed and undiagnosed MDD adversely affects patients who undergo MPFL reconstruction. Requiring a TTO or having an underlying connective tissue disorders may present as additional risk factors. These findings highlight the importance of identifying and addressing mental health in this patient population, especially given the number of patients who did require contralateral MPFL (with subsequently longer recovery times) and therefore may be susceptible to inferior long-term physical function.
