Psychological burden of bone and joint infections: Systematic review on mental health and quality of life implications

Abstract

BACKGROUND

Bone and joint infections (BJIs), such as periprosthetic joint infections and fracture-related infections, are severe complications in orthopedic surgery with profound physical, social, and psychological consequences. While their physical and economic impacts are well documented, the psychological burden remains underrecognized.

AIM

To systematically review the existing literature on the impact of BJIs on mental health and quality of life, and to identify validated tools used to assess these outcomes.

METHODS

Systematic review was conducted on PubMed and Scopus database. Seventeen studies published between 2010 and 2024 were included (5 qualitative, 12 quantitative).

RESULTS

Qualitative findings revealed consistent emotional suffering, including fear, helplessness, depression, and social withdrawal, especially during the interim phase of two-stage revisions. Quantitative studies confirmed a significant deterioration in mental health, even after clinical resolution of the infection. Among the tools employed, the International Classification of Diseases-10-Symptom Rating and the Hospital Anxiety and Depression Scale emerged as the most sensitive for detecting psychological distress.

CONCLUSION

Despite growing awareness, there is still a lack of specific psychological interventions and standardized assessment protocols for this vulnerable patient population. These findings underscore the urgent need for integrating mental health evaluation and support into comprehensive BJI treatment strategies to improve outcomes and long-term quality of life.

Key Words: Mental health; Bone infection; Periprosthetic joint infection; Fracture related infection; Anxiety; Depression; Quality of life; Psychopathology

Core Tip: This is the first systematic review to explore the psychological impact of bone and joint infections (BJIs), including periprosthetic joint infections and fracture-related infections. By analyzing both qualitative and quantitative studies, we demonstrate that BJIs cause substantial and persistent emotional distress - comparable to oncologic conditions - especially during complex treatment phases. The International Classification of Diseases-10-Symptom Rating and Hospital Anxiety and Depression Scale scales emerged as the most sensitive assessment tools. Our findings call for urgent integration of mental health evaluation and targeted psychological support in BJI care pathways to improve patient outcomes and quality of life.

INTRODUCTION

Bone and joint infections (BJIs) are a devastating complication in orthopedic surgery, placing a significant burden on the patients, their families, and healthcare systems[1]. These infections are serious medical conditions with significant implications for both morbidity and mortality[2,3]. In the literature, considerable attention has been given to the compromised physical outcome and the socioeconomic damage caused by osteoarticular infections[3,4]. Patients are faced with immobility, up to amputation of the affected limb, pain, prolonged hospital stay, multiple surgeries, and the administration of local and systemic antibiotics, often associated with side effects, as well as job loss and further negative socio-economic consequences[1,5,6]. Physical limitations, including difficulties with even simple daily activities, have been documented following revision surgery in patients with BJIs[7]. In a large study, Wildeman et al[3] demonstrated that hip periprosthetic joint infection (PJI) was associated with increased use of ambulatory aids and decreased quality of life (QoL) at a 10 - year minimum follow-up. The extended period of immobility and hospitalization can disrupt the patient’s financial stability and social well-being. The financial burden should not be underestimated, as direct healthcare costs for patients (or national healthcare systems) with surgical site infections have been found to be nearly twice as high as those for non-infected patients[8]. On the other hand, less attention is often given to the psychological burden in the aftermath of such infections. This aspect becomes particularly evident when considering that treatment success is mainly defined as the eradication of the infection symptom, while psychological aspects are often underestimated[6]. Numerous studies have shown that pre-existing mental health disorders place patients at increased risk of developing PJI, but the role that chronic PJI treatment plays in the development and relapse of mental health disorders remains largely unreported[9].

Therefore, the aim of this systematic review is twofold: Primarily to summarize current evidence on the psychological burden experienced by patients with BJIs; and subsequently to identify and evaluate the measurement tools used to assess mental health outcomes and QoL in this patient population. In particular, this work seeks to understand which psychological consequences are most frequently reported by patients during and after treatment, and how effectively available psychometric instruments capture these complex emotional experiences.

MATERIALS AND METHODS

A systematic review of the literature was performed by consulting two scientific databases: Scopus and PubMed. Our research was conducted using the patient, intervention, comparison, outcome model and following the PRISMA flowchart (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)[10]. First, we developed the search query lines using keywords from both the mental health domain and the BJI domain, combined together [i.e., PJI, fracture-related infection (FRI), osteomyelitis, anxiety, depression]. Studies were collected according to the following inclusion criteria: Articles written in English, published between January 2010 and December 2024, including patients with a history of surgically treated BJI and the use of a dedicated questionnaire (tools or interview) to assess mental health and QoL after the diagnosis of BJI. Studies based on animal experiments were excluded. Studies involving patients with a pre-existing mental illness were excluded from the analysis in order to analyze only the impact of the BJI diagnosis and treatment on the patient’s mental health. After eliminating duplicates, two authors (De Meo D and Staccini D) separately identified publications for eligibility and resolved any disagreements by consensus. After the final selection, data were extracted from the included articles, and the analysis was conducted by dividing the studies into two groups: Qualitative and quantitative analysis. The qualitative group included articles that used telephone or in-person interviews. Articles that employed standardized questionnaires to assess QoL and mental health were included in the quantitative group. Data were organized and analyzed using Microsoft Excel 2021 (Microsoft Corporation, Microsoft 365 version, 2025). The authors then assessed the level of evidence of each study according to the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence (https://www.cebm.net/home/).

RESULTS

A total of 633 articles were initially identified through the search query lines (Figure 1). Before screening, 189 duplicate records were removed. The remaining 444 studies were assessed for eligibility. Studies published before January 2010 and those not written in English were excluded (n = 178). We included only studies conducted on human cohorts, published between 2010 and 2024, that employed validated questionnaires to assess mental health and QoL. Additionally, we considered only studies involving patients with a history of treated osteoarticular infections and subsequent diagnosis and evaluation of mental health outcomes. Applying these criteria, 24 studies were selected for full-text examination. In the final analysis, we included 17 studies. The selected studies were categorized into two subgroups: A qualitative group based on in-person or telematic interviews (n = 5) and a quantitative group that used structured questionnaire models (n = 12) (Figure 1)[1,7,8,11-24]. The level of evidence among these was: Seven studies at level II[1,15-19,24], two studies at level III[8,22], three studies at level IV[20,21,23], and five studies at level V[7,11-14].

Figure 1 Preferred Reporting Items for Systematic reviews and Meta-Analyses - flow diagram of the systematic review. Adapted from Page et al[10].

Qualitative analysis

One of the first qualitative studies on the psychological impact of PJI and its surgical management was conducted by Moore et al[14], involving 19 patients across five National Health Service centers in England and Wales. The study compared patient experiences following one-stage (OS) vs two-stage (TS) revision procedures, revealing a greater emotional and psychological burden in the TS group, largely due to the prolonged immobilization between surgeries. Participants’ narratives were organized into three phases - symptom onset, treatment period and recovery process - each associated with specific psychological challenges and disruptions to everyday life: The insidious nature and invalidated concerns for symptom onset phase; mobility and lifestyle limitations, impact on family and relationships, and antibiotic burden for the treatment period; and physical limitations, loss of valued activities, social impact and uncertainty for the protracted recovery phase. The authors emphasized the need for specific psychosocial support tailored to the various stages of illness and recovery.

Mallon et al[13] conducted a thematic analysis of 16 patients who had undergone revision surgery for prosthetic knee infection. Through semi-structured interviews, the authors identified three core themes reflecting biographical disruption: (1) Difficulties in symptom recognition and diagnosis; (2) Emerging disability and future uncertainty; and (3) Chronic illness that requires mobilization of personal and external resources. Patients considered the PJI as a life-changing event, describing it as “devastating”, “traumatic”, and causing a “considerably restricted life”. Consistent with Bury’s theory of biographical disruption[25], patients reported how the infection forced them to renegotiate their daily life, future plans, and sense of normality. Participants reported substantial disruptions to daily routines, uncertainty about the course and outcomes of infection and treatment, and anxiety about the future. Many described the diagnosis as a traumatic and disorienting event, with little preparation for the challenges that followed. The findings highlighted how periprosthetic knee infection can be a life-altering experience, reinforcing the need for comprehensive psychological and empathetic support during and after treatment. Notably, both above-mentioned studies illustrate how PJI and the need for surgical revision affect patients’ lives on multiple levels and at various stages: These include the onset of symptoms, the burden of surgical procedures, the resulting limitations in mobility and independent living, and, ultimately, the shift in existential perspective associated with perceiving the condition as chronic.

Other studies have compared the psychological impact of OS and TS revision of PJI. Palmer et al[7] adopted an inductive comparative methodology to investigate patient experiences following different revision strategies, finding differences according to the type of surgery and spacer used. This study enrolled 32 patients and highlights that those treated with TS revision with an excised hip or a cement spacer reported the greatest limitations in mobility and QoL, while those who received articulating spacers retained greater autonomy. Patients who underwent TS revision with an excised hip or a cement spacer experienced the most severe mobility restrictions, with considerable negative impact on QoL. In contrast, those treated with articulating spacers - whether in OS or TS procedures - reported fewer limitations and retained a relatively independent lifestyle. However, patients with cement spacers reported significantly more pain, while articulating spacers were associated with slower recovery. Across all groups, long-term (18 months) outcomes were characterized by a combination of functional improvement and persistent limitations. Many participants reported the lack of adequate psychological and informational support throughout the treatment pathway. The study also highlighted the broader impact of PJI on family dynamics and patients’ perception of a “changed life” following infection and surgery. Interestingly, despite these challenges, several patients demonstrated emotional resilience, suggesting the development of personal coping strategies to manage the condition. These findings underline the importance of ongoing psychological monitoring as a key component of rehabilitation after joint replacement.

Similarly, in 2022, Rowland et al[11] explored the lived experiences of 10 patients undergoing OS or TS knee revisions for PJI, before, during, and after hospitalization. Participants described the infection as a life-changing event in their life, associated with multifaceted physical, psychological, and social consequences. Psychological sequelae included depressive symptoms, anxiety, and emotional distress, primarily due to pain, weight loss, fatigue, reduced mobility, and dependence on caregivers. Delayed diagnosis and treatment were identified as significant complicating factors. Notably, pain was described not only as a physical factor but also as a mental burden affecting patients’ mood, to such a degree that some participants identified it as depression. The occurrence of chronic pain was described as a persistent source of anxiety, significantly impairing their QoL.

Lastly, a recent study conducted in 2023 by Wimalan et al[12] in Germany used semi-structured interviews to explore the emotional and psychological impact of FRI in 20 patients. Three major themes emerged: (1) FRI significantly limited daily functioning and autonomy, resulting in frustration, anxiety and fear even after clinical resolution; (2) Socioeconomic consequences, including job loss or limitations and financial strain, contributed to emotional vulnerability; and (3) Patients relied on personal coping strategies - particularly spirituality and meditation - to manage distress and regain emotional balance. Across the analysed qualitative studies, recurring psychological dimensions were described, including the traumatic perception of infection, the burden of physical impairment, emotional distress related to chronicity and prognostic uncertainty, and the gradual development of coping mechanisms. In studies on PJI, distinctions emerged between OS and TS revision procedures, particularly in terms of perceived burden and post-operative recovery trajectories. Overall, PJI and the associated need for surgical revision significantly affect patients’ QoL across multiple domains - from symptom onset and surgical burden to long-term functional limitations and reduced autonomy, ultimately contributing to existential distress related to the chronic nature of the condition.

Quantitative analysis

The quantitative analysis included 12 studies (Table 1)[1,8,15-24]. omprising a total of 420 patients: 247 males (58,8%) and 173 females (41,2%), with a mean age ranging from 35 years to 71.6 years[1,8,15-24]. Most studies (n = 8) focused on PJI[15-19,21-23], while seven studies also included FRI or osteomyelitis[1,8,15,20,21,23,24]. One study included individuals with septic arthritis[15]. Only 10 studies explicitly reported the type of treatment administered[15-24], while in two studies, treatment was not specified[1,8]. Regarding study design, five studies were prospective[15,16,18,19,24], six were retrospective[1,8,17,20,22,23], and one multicenter study collected data ambispectively[21]. Four studies included control groups for comparison[1,8,15,17].

Table 1 Articles included into quantitative study.

Ref.	Study design	n	Age (mean)	Sex	Type of infection	Anatomical site	Surgical treatment	Control group, if any
Wixted et al[15], 2022	Prospective	35	60	19 (M), 16(F)	PJI, SA, OM	Hip	R/A (Girdlestone)	United States general population
Walter et al[16], 2024	Prospective	29	71.4	14(M), 15(F)	PJI	Hip (14), knee (15)	DAIR (7), OSE (1), TSE (19), amputation (2)	NA
Walter et al[1], 2021	Retrospective	37	59.5	25 (M), 12 (F)	FRI	Humerus (5), femur (10), tibia (18), fibula (1), forearm (3)	NS	Normative data (general German population)
Walter et al[17], 2021	Retrospective	36	71.6	19 (M), 17(F)	PJI	Knee	DAIR (16), OSE (3), TSE (8), arthrodesis (9)	Normative data (general German population)
Knebel et al[18], 2020	Prospective	31	69	16 (M), 15 (F)	PJI	Knee	TSE	Normative data (general German population)
Maurer et al[8], 2022	Retrospective	25	55.5	18 (M), 7 (F)	FRI	Foot	NS	Normative data (general German population)
Lueck et al[19], 2022	Prospective	27	69.9	11 (M), 16 (F)	PJI	Hip (14), knee (13)	TSE	NA
Walter et al[20], 2021	Retrospective	13	43.9	8 (M), 5 (F)	FRI	Tibia	Gentamicin-coated intramedullary nail	Open tibial fractures, aseptic non - union
Klim et al[21], 2023	Ambispective	48	63.6	32 (M), 16 (F)	PJI (25), OM (23)	Hip (10), knee (14), shoulder (2), femur (7), tibia (11), foot (1), forearm (1), humerus (2)	Treatment-resistant PJI or OM, living with a natural or iatrogenic sinus tract	NA
Helwig et al[22], 2014	Retrospective	84	69	53 (M), 31 (F)	PJI	Hip (41), knee (43)	DAIR, OSE/TSE, R/A	NA
Walter et al[23], 2022	Retrospective	20	67.3	11 (M), 9 (F)	PJI (14), FRI (6)	Knee PJI (14), FRI (proximal tibia 4, distal femur 2)	Temporary arthrodesis with PMMA - coated intramedullary nail reinforced with cerclage wire	NA
Abulaiti et al[24], 2017	Prospective	35	35	21 (M), 14 (F)	OM	Tibia	Bone transport with external fixation ± membrane induction or bone grafting	NA

n: Number of patients included in the study; M: Male; F: Female; PJI: Periprosthetic joint infection; OM: Osteomyelitis; SA: Septic arthritis; R/A: Resection or arthrodesis; DAIR: Debridement, Antibiotics, and implant retention; OSE: One-stage exchange; TSE: Two-stage exchange; FRI: Fracture-related infection; NS: Not specified; NA: Not available; PMMA: Polymethyl methacrylate.

Various validated instruments were used to assess mental health and QoL outcomes. Among the included quantitative studies, six studies[1,8,16,17,20,23] incorporated the EuroQoL - 5 Dimension (EQ-5D)[26] (Table 2) and the International Classification of Diseases-10-Symptom Rating (ISR)[27] (Table 2). Eight studies[1,8,16,17,19-21,23] implemented the Short-Form 36 (SF-36) questionnaire[28] (Table 3), while two studies[18,22] administered the SF-12[29]. In the study by Wixted et al[15], the Prosthesis Evaluation Questionnaire[30] and the patient-reported outcomes measurement information system (PROMIS)[31] were utilized. The Patient Health Questionnaire-4[32] was used exclusively in the study by Knebel et al[18] while the Hospital Anxiety and Depression Scale (HADS)[33] was administered in two studies[19,21]. The Symptom Checklist-90[34] questionnaire was implemented in the study by Abulaiti et al[24]. Additionally, three studies[16,18,19] included further instruments to investigate patients’ expectations, life satisfaction, and fear of disease progression.

Table 2 Post-surgical Euro Quality of Life-5 Dimension index, Euro Quality of Life-5 Dimension visual analogue scale, International Classification of Diseases-10-Symptom Rating total, International Classification of Diseases-10-Symptom Rating anxiety, International Classification of Diseases-10-Symptom Rating depression scores.

Ref.	EQ-5D index	EQ-5D VAS	ISR total	ISR anxiety	ISR depression
Walter et al[1], 2021	0.76	65.7	0.55	0.49	0.78
Maurer et al[8], 2022	0.66	62.1	0.74	0.86	1.23
Walter et al[17], 2021	0.55	52.14	0.53	0.43	1.06
Walter et al[20], 2021	0.769	62.6	0.64	0.66	1.23
Walter et al[23], 2022	0.361	47.41	0.521	0.741	1.181
Walter et al[16], 2024	Severe limitations decreased from 56% preoperatively to 33% at 12 months for mobility, self - care, and usual activities; anxiety/depression limitations showed fluctuations with mild limitations reaching their peak at 63% at three months before decreasing to 48% at 12 months2	49 (peak at 3 months after surgery)	0.87 (12 months after surgery)	1.12 (peak at 12 months after surgery)	1.6 (peak at 6 months after surgery)

¹Mid-treatment period.

²Data presented in a non-index form in the paper.

EQ-5D: Euro Quality of Life-5 Dimension; VAS: Visual analogue scale; ISR: International Classification of Diseases-10-Symptom Rating.

Table 3 Post-surgical Short-Form 36 scores.

Author	PCS SF-36 postoperative results	MCS SF-36 postoperative results
Walter et al[1], 2021	40.1	48.7
Maurer et al[8], 2022	35.6	41.3
Walter et al[16], 2024	26.9	35.24
Walter et al[17], 2021	24.86	46.16
Lueck et al[19], 2022	31.7	52.4
Walter et al[20], 2021	40.18	39.58
Klim et al[21], 2023	33.9	50.2
Walter et al[23], 2022	26.11	47.11

¹Mid-treatment period.

PCS: Physical health component score; MCS: Mental health component score; SF-36: Short-Form 36.

Regarding the time of questionnaire administration, most studies[1,8,15,17,20-22] collected data exclusively during the postoperative period. One study[16] assessed patients both before and after surgery. In three studies[18,19,24], questionnaires were administered at three time points: Preoperatively, during treatment (intermediate phase), and postoperatively. One study[23] focused exclusively on the intermediate treatment period. Focusing on the studies that included a control group[1,8,15,17,18], Wixted et al[15] reported that, although treatment had a significant impact on patients’ physical function, mental well-being, and social activity were only moderately affected. Specifically, the mean PROMIS Global Physical Health score was 10.3 points lower than that of the control group, while the PROMIS Global Mental Health score was 3.9 points lower compared to the United States general population. In the study by Maurer et al[8], a significant discrepancy was observed in the mean scores of the SF-36 components. The Physical Component Summary (PCS) and the Mental Component Summary (MCS) scores were 35.6 ± 12.3 and 41.3 ± 12.9, respectively, in the patient group, compared to 45.7 ± 9.4 and 51.0 ± 9.2 in the control group (general German population; P < 0.001). Similarly, Walter et al[17] demonstrated a substantial impact of BJIs on patients’ QoL; notably, the mean PCS of the SF-36 reached only 51.3% and the EQ-5D index value 65.7% of the normative scores (normative data derived from the general population of Germany, P < 0.001). Furthermore, the use of the ISR revealed that patients showed moderate to severe psychological impairments based on the total ISR score, with a mean total value of 0.55[1].

Studies that administered questionnaires in the post-operative period, as well as in the pre-operative phase or during the intermediate treatment period, provide a broader perspective on the evolution of the patient’s symptomatology[16,18,19,24]. For example, in the study conducted by Walter et al[17], the total ISR score increased from 0.55 in the pre-operative period to 0.87 at twelve months post-operatively (P = 0.002)[16]. The results obtained from the SF-36 also indicate a deterioration in both physical and mental health domains that progresses over time, with PCS and MCS scores of 26.9 and 35.24, respectively, twelve months post-operatively (P = 0.023)[16].

Knebel et al[18] reported that 18 out of 31 patients (58.1%) had a Patient Health Questionnaire-4 score above the cut-off for depression at least once during follow-up. SF-12 scores also confirmed reduced health-related QoL, with mean MCS and PCS scores of 42.6 and 26.9, respectively, the latter being significantly lower than that of the control group[18]. In the assessments conducted by Lueck et al[19], SF-36 PCS scores decreased from 31.8 in the preoperative phase (A1) to 25.7 during the intermediate period between treatment stages (A2), and then increased again to 31.7 after the definitive treatment (A3). A similar trend was observed for MCS scores, with values of 56.8 (A1), 31.7 (A2), and 52.4 (A3), showing statistically significant differences between A1 and A2 (P < 0.001) and between A2 and A3 (P < 0.001). Moreover, the HADS scores for depression and anxiety showed the worst values during the intermediate period (A2), with scores of 13.4 and 13, respectively - a marked increase compared to the preoperative period (A1), where the scores were 5.5 and 4.6, respectively[19]. A summary of the results of the included studies is listed in Table 4.

Table 4 Summary table.

Ref.	Study design	Type of infection	Surgical treatment	Major mental health consequence
Wixted et al[15], 2022	Prospective	PJI, SA, OM	R/A (Girdlestone)	Moderate effects on mental health
Walter et al[16], 2024	Prospective	PJI	DAIR (7), OSE (1), TSE (19), Amputation (2)	The treatment of PJI can lead to a significant psychological burden, particularly anxiety and depression
Walter et al[1], 2021	Retrospective	FRI	Treatment performed but not specified	Mental health consequences are common after FRI and are often reflected in a range of depressive symptoms
Walter et al[17], 2021	Retrospective	PJI	DAIR (16) OSE (3) TSE (8) Arthrodesis (9)	The treatment of PJI can lead to a significant psychological burden, particularly depression
Knebel et al[18], 2020	Prospective	PJI	TSE	PJI represents a significant psychological stressor for patients, particularly in terms of fear of disease progression, anxiety, and depression
Maurer et al[8], 2022	Retrospective	FRI	Treatment performed but not specified	The mental well-being of affected patients remains impaired, even after successful treatment of FRI
Lueck et al[19], 2022	Prospective	PJI	TSE	HADS assessments indicate elevated levels of anxiety and depression in patients with PJI, especially during the intermediate phase of treatment
Walter et al[20], 2021	Retrospective	FRI	Gentamicin - coated intramedullary nail	Even after successful treatment, patients may continue to suffer from a reduced quality of life, particularly affecting the psychological sphere
Klim et al[21], 2023	Retrospective + Prospective	PJI (25), OM (23)	Treatment-resistant PJI or OM, living with a natural or iatrogenic sinus tract	Mental health is mildly affected
Helwig et al[22], 2014	Retrospective	PJI	DAIR, OSE/TSE, R/A	Quality of life is reduced, mental health is mildly affected
Walter et al[23], 2022	Retrospective	PJI (14), FRI (6)	Temporary arthrodesis with PMMA - coated intramedullary nail reinforced with cerclage wire	In the study cohort, a psychological symptom burden on the depression scale and elevated levels of anxiety were observed compared to healed patients
Abulaiti et al[24], 2017	Prospective	OM	Bone transport with external fixation ± membrane induction or bone grafting	External fixation had a negative impact on the patients’ mental health
Rowland et al[11], 2023	Retrospective	PJI	OSE/TSE	PJI can lead to significant physical limitations and social isolation, placing patients at increased risk for psychological distress, ranging from persistent worry to clinical depression
Wimalan et al[12], 2023	Retrospective	FRI	Treatment performed but not specified	FRI had a negative impact on mental well-being, as patients developed persistent anxiety and other psychological disturbances
Mallon et al[13], 2018	Retrospective	PJI	OSE/TSE	Profound physical, social, psychological, and financial disruptions were observed in all participants
Palmer et al[7], 2020	Retrospective	PJI	OSE/TSE	Adversely affected quality of life, particularly in terms of psychological well-being
Moore et al[14], 2015	Retrospective	PJI	OSE/TSE	Patients experienced psychological distress, such as anxiety and depression, especially during the interval period

PJI: Periprosthetic Joint Infection; OM: Osteomyelitis; SA: Septic arthritis; R/A: Resection or arthrodesis; DAIR: Debridement, Antibiotics, and implant retention; OSE: One-stage exchange; TSE: Two-stage exchange; FRI: Fracture-related infection; PMMA: Polymethyl methacrylate; HADS: Hospital Anxiety and Depression Scale.

DISCUSSION

This systematic review highlights the significant psychological burden associated with BJI. To our knowledge, this is the first systematic review specifically aimed at investigating the psychological burden of BJIs and related surgical revisions on patients’ experiences. Evidence is increasingly demonstrating how the psychological impact of such severe orthopedic conditions may predict both medical and functional outcomes, underscoring the need for a deeper understanding of their consequences. We believe that this systematic review stands out for its original methodological approach, which is based on separate analysis based on the qualitative and quantitative nature of collected data. Indeed, it becomes clear that a qualitative approach to the psychological burden of BJIs is essential to capture the inner and subjective experiences involved, whilst a purely quantitative approach would risk losing the complexity of these aspects. This dual approach allows for a more nuanced understanding of the emotional challenges and coping strategies adopted by patients facing these complex orthopedic infections.

The reviewed qualitative studies consistently emphasize the need to address the psychological and emotional impact of BJIs and their treatment. One of the key factors contributing to this impact is the lack of adequate information and insufficient preparation for the emotional challenges posed by surgical procedures for BJI. Physicians must raise awareness about this highly burdensome condition by improving patient education, supporting patients’ coping abilities, and strengthening their own clinical preparedness and skills.

On the other hand, quantitative studies reinforce these insights, considering the heterogeneity of the different approaches to measure impact on mental health of BJIs. Most of the studies, derived from a single group, used a combination of scales (EQ-5D, ISR, SF-36)[1,8,16,17,19-21,23], while others applied different instruments to assess mental health impact[15,16,18,19,21,22,24]. Despite this variability, results consistently indicate that psychological burden tends to increase even after successful treatment[17]. Notably, the highest psychological burden is often observed during the interim phase of the TS revision approach. Not all the scales, anyway, are able to capture the psychological status of BJI patients. Among those reviewed, the ISR and the HADS appear to be the most accurate in detecting changes in patients’ psychological status over time[1,19,21].

The physical burden of BJI, along with the occurrence of pain (whether long-term or chronic) and concerns about reinfection or permanent disability, appears to contribute to psychological distress, including anxiety and depression[26]. The fear of disease progression, with its significant impact on QoL, and the perceived chronic nature of the condition make the burden of BJI comparable to that experienced by oncology patients. Furthermore, BJI and its treatment may affect family structure and resources, leading to significant changes in the social environment, such as the need for support with personal hygiene, daily tasks, and medication management. These factors have been reported to give rise to feelings of indignity, helplessness, demoralization, and depression, highlighting a critical issue that needs to be addressed[35]. It is well established that BJIs have a considerable impact on health-related QoL and patients’ mental health. However, there is currently no evidence supporting the implementation of brief, targeted psychological interventions specifically tailored to this patient population[16,35]. These findings corroborate that qualitative research is uniquely suited to capture the depth and complexity of patients’ subjective emotional experiences - dimensions that are often missed by quantitative methodologies. Therefore, it is essential to promote and implement new qualitative studies grounded in inductive approaches. Thematic analysis should have the goal of identifying core psychological themes and inform the development of tailored supportive interventions.

However, data exploring the relationship between BJI, its treatment, and mental health outcomes remains scarce and heterogeneous. It is important to underscore the considerable heterogeneity in study methodologies, patient populations, and treatment strategies across the included studies, which may influence the comparability of results. Moreover, several of the included studies were limited by retrospective designs and small sample sizes. Notably, mental health outcomes are often underreported or insufficiently explored in orthopedic literature, potentially leading to an underestimation of the psychological burden of BJIs. Future qualitative studies and controlled trials are warranted to assess the potential benefits of psychopharmacological and psychosocial interventions aimed at improving emotional well-being and overall QoL for individuals affected by BJI. Although most studies to date have focused on PJI involving major joints[11,13,36,37], further research is urgently needed to investigate infections affecting other articular and skeletal sites. Upcoming research should emphasize the design and validation of specialized assessment tools, in-depth qualitative investigations of patient perspectives, and rigorous clinical trials to determine the benefits of psychological and social support interventions. Moreover, there is a substantial clinical difference between PJI and FRI that can impact psychological outcome as well. FRI poses a challenge of infection resolution and fracture healing: Those two objectives cannot always be achieved together[38], and therefore, full recovery often requires more surgeries and prolonged time. Moreover, this complication happens after an unexpected event (the trauma that originated the fracture) that suddenly alters the routine of the patients and can harm their stability[1].

CONCLUSION

BJI, particularly PJI and FRI, impose a significant psychological and emotional burden on affected patients, often comparable to chronic and life-threatening diseases such as cancer. This systematic review highlights the lack of adequate attention to the mental health sequelae of BJI, both in clinical practice and scientific literature. Despite the heterogeneity of assessment tools and the limited number of high-quality studies, there is consistent evidence indicating that anxiety, depressive symptoms, and psychological distress are common and may persist even after infection resolution. The interim phase of TS exchange procedures and the prolonged, uncertain course of BJI are particularly critical in exacerbating emotional suffering. However, the current tools used to assess mental health impact vary widely, with the ISR and HADS scales emerging as the most sensitive in detecting changes over time. There is an urgent need for multidisciplinary care models that include mental health support as an integral part of the BJI management. Future studies should prioritize the development and validation of tailored psychometric tools, qualitative research to capture patients’ lived experiences, and clinical trials assessing the effectiveness of psychotherapeutic and psychosocial interventions. Ultimately, a better understanding of the psychological dimension of BJI is crucial to improving patients’ QoL and treatment outcomes.