Study: Perioperative Counseling Boosts Function for Adolescents Undergoing Hip Preservation Surgery

By Josh Garcia
Friday, December 7, 2018
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Adolescents who received psychological education and counseling before and after hip preservation surgery (HPS) exhibited enhanced psychological and physical function, according to a recent study.

The link between psychological stressors and physical symptoms is a frequent line of inquiry in orthopedics. A 2017 study in The Journal of Arthroplasty found that the severity of symptoms related to femoroacetabular impingement (FAI) was “significantly more related to mental health status than either the size of labral tear or FAI deformity.” An earlier study in The Journal of Bone & Joint Surgery found similar results for patients with full-thickness rotator cuff tears.

For David Podeszwa, MD, Associate Professor in the Department of Orthopedic Surgery at the University of Texas Southwestern Medical Center and Attending Surgeon at Texas Scottish Rite Hospital for Children, an experience with a young patient led him to delve into the topic.

“A patient who had HPS needed to be readmitted because of pain,” Dr. Podeszwa says. “We couldn’t find a clinical reason for it, but we found psychosocial stressors in the patient’s home environment. We realized how much of an influence these stressors had on the child, which drove us to perform research.”

Identifying Stressors

Dr. Podeszwa was involved with two studies that examined adolescents selected for HPS, both published in the Journal of Pediatric Orthopaedics. His research found that up to a third of patients reported maladaptive behavior prior to HPS.

While chronic pain can contribute to anxiety and depression, issues such as social isolation can exacerbate maladaptive behaviors, especially in children with underlying mental health symptoms, he notes.

After recognizing psychological “red flags” in adolescent patients indicated for HPS in his first study, Dr. Podeszwa set out to determine whether interdisciplinary intervention, including perioperative psychological education and counseling, could improve outcomes.

Mitigating Symptoms

During the second study, patients and families were asked to contact psychologists and engage with physical therapists presurgically. Psychologists worked with patients in an inpatient setting at the time of surgery and again during follow-up.

Though the study does not purport to establish a causal relationship between psychological intervention and improved outcomes, there were significant improvements in psychological and physical function among patients who participated in the intervention. Participants completed multiple self-report measures pre- and postoperatively, including the Behavioral Assessment System for Children, Second Edition (BASC-2), the Resiliency Scales for Children and Adolescents (RSCA), the University of California—Los Angeles (UCLA) activity scale and the modified Harris Hip Score (mHHS).

BASC-2 anxiety scores dropped from 49.6 preoperatively to 45.8 postoperatively, and sense-of-inadequacy scores decreased from 49 to 46. RSCA scores for vulnerability dropped from 47.7 to 44.7. On the physical side, the average UCLA activity score improved from 7.1 to 8.7, and mHHS scores improved from 67.3 to 83.8.

“Our next step is refining the process in which we evaluate these children,” Dr. Podeszwa says. “This would [identify] the most important questions that other providers could ask, especially if they need to refer patients to psychologists outside of their institutions.”