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

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.

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.

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.