Psychological status in femoral neck fractures: Effects on pain, comfort, and postoperative recovery

Abstract

BACKGROUND

The correlation between psychological status and pain, comfort, and postoperative recovery in patients with femoral neck fracture (FNF) has rarely been examined, yet its potential influence on recovery cannot be overlooked.

AIM

To examined how psychological status affects pain, overall comfort, and postoperative recovery in patients with FNF.

METHODS

A total of 125 patients with FNF (treated from May 2022 to February 2025) were stratified by anxiety [Self-Rating Anxiety Scale (SAS) > 50] and depression [Self-Rating Depression Scale (SDS) > 53]. Comparisons were made between anxiety (n = 56) vs non-anxiety (n = 69) and depression (n = 50) vs non-depression (n = 75) groups regarding pain [Visual Analog Scale (VAS)], overall comfort [General Comfort Questionnaire (GCQ)], and recovery [Harris Hip Score and Activities of Daily Living Scale (ADL)]. Correlations between psychological distress and pain, overall comfort, and postoperative recovery were also analyzed.

RESULTS

FNF patients with anxiety or depression experienced significantly worse pain (higher VAS scores), greater discomfort (lower GCQ scores), and slower recovery (reduced Harris and ADL scores). According to correlation analysis, SAS/SDS scores showed weak positive correlations with VAS and weak negative correlations with GCQ, Harris, and ADL scores.

CONCLUSION

Psychological status show a weak but meaningful correlation with pain, overall comfort, and postoperative recovery in patients with FNF, highlighting the potential value of targeted psychological distress interventions to improve analgesia, overall comfort, and postoperative rehabilitation.

Key Words: Femoral neck fracture; Psychological status; Pain; Comfort; Postoperative recovery

Core Tip: This study included 125 patients with femoral neck fracture (FNF) to analyze the correlation between psychological status and pain, overall comfort, and postoperative recovery. Our analyses revealed that patients with FNF commonly exhibited mild anxiety or depression; such symptoms were closely related to severer pain, worse overall comfort, and poorer postoperative functional recovery. Psychological distress showed weak associations with pain, overall comfort, and postoperative recovery. Routine psychological screening and targeted psychological interventions may help reduce pain, improve overall comfort, and enhance functional prognosis in patients with FNF.

INTRODUCTION

Femoral neck fractures (FNFs), a subset of hip fractures, account for more than half (53.0%) of cases and fall under proximal femoral fractures (along with intertrochanteric fractures), predominantly affecting middle-aged and older adults[1,2]. Global prevalence is expected to increase, reaching 3.2 million cases by 2050[3]. FNFs pose substantial health risks, with a one-year post-fracture mortality rate of 22.0%[4]. Among survivors, nearly half also lose functional independence, and one-third require full assistance with activities of Activities of Daily Living Scale (ADL)[5]. Known risk factors include female sex, low body weight, osteoporosis, and obesity[6]. Severe pain from fractured bone ends can trigger complex physiological responses, hinder postoperative recovery, and induce psychological distress, worsening the biopsychosocial negative feedback loop[7,8]. Additionally, mobility limitations and loss of independence disrupt daily routines and employment, often leading to anxiety and depressive symptoms[9]. Surgery-related injury and social changes may further heighten psychological distress in patients with FNF[10], impairing endocrine and immune function, reducing treatment efficacy, and hindering recovery[11].

Despite this, the psychological aspects of patients with FNF and their impact on postoperative pain, comfort, and rehabilitation have received insufficient attention. By addressing this gap, our study offers clinically relevant insights to support better postoperative outcomes.

MATERIALS AND METHODS

General data

We enrolled 125 patients with FNF treated between May 2022 and February 2025. According to anxiety [Self-Rating Anxiety Scale (SAS) > 50] and depression [Self-Rating Depression Scale (SDS) > 53] scores, patients were classified into anxiety (n = 56) vs non-anxiety (n = 69) groups and depression (n = 50) vs non-depression (n = 75) groups.

Case selection criteria

Eligibility criteria: (1) Diagnosis consistent with FNF[12]; (2) Surgical candidates after unsuccessful conservative therapy; (3) Complete clinical data; and (4) No cognitive or communication impairment.

Exclusion criteria: (1) Severe neurological diseases affecting lower-limb motor, sensory, or coordination functions [e.g., severe Parkinson’s disease (Hoehn and Yahr stage 4 or 5), active multiple sclerosis, hemiplegia due to prior stroke with modified Rankin Scale score > 3]; (2) Severe hematological disorders, including uncorrected coagulopathy (e.g., international normalized ratio > 1.5 unrelated to anticoagulation or platelet count < 80 × 10⁹/L), active hemorrhage, or high-risk hematopathy; (3) Serious cardiovascular disease (New York Heart Association Class III-IV, acute myocardial infarction or unstable angina within six months, stroke, symptomatic ventricular tachycardia, or advanced atrioventricular block); (4) Severe renal disease (chronic kidney disease stage 4-5 within an estimated glomerular filtration rate < 30 mL/minute/1.73 m² or dialysis dependence, or acute kidney injury); (5) Long-term use of immunomodulatory or hematologically active drugs (e.g., anticoagulants, steroids); (6) Acetabular posterior defects, marked femoral deformity, hip ankylosis, or inflammatory hip disease; (7) Prior hip surgery or history of cerebral infarction/thrombosis; (8) Coagulation disorders, extreme obesity (body mass index > 40 kg/m²), active systemic or local infection; and (9) Malignancies. The screening flowchart is shown in Figure 1.

Figure 1 Flowchart of patient selection.

Detection indicators

Pain intensity: The Visual Analog Scale (VAS)[13], rated pain from 0 (none) to 10 (most severe), with higher scores indicating more severe pain.

Psychological status: Anxiety and depression were assessed using SAS and SDS[14]. SAS score ranges were 50-59 (mild), 60-69 (moderate), and ≥ 70 (severe). SDS severity thresholds were 53-62 (mild), 63-72 (moderate), and ≥ 73 (severe).

Comfort: The 28-item General Comfort Questionnaire (GCQ)[15], scored 1-4 per item, quantified comfort, with higher totals reflecting greater comfort.

Postoperative recovery: Postoperative recovery was evaluated using the ADL scale[16], consisting of 10 items totaling 100 points; Higher scores indicate better daily functioning. Hip function was assessed using the Harris scale (maximum of 100 points) in which lower scores indicated poorer joint recovery.

Statistical analysis

Continuous variables met parametric assumptions verified using Bartlett’s test for homogeneity of variance and Kolmogorov-Smirnov test for normality. Group comparisons used independent t-tests for continuous data (presented as mean ± SD) and χ² tests for categorical data (shown as percentages). Pearson/Spearman correlations assessed variable relationships. Analyses were conducted using SPSS 26.0, with P < 0.05 considered statistically significant.

RESULTS

Psychological status of the 125 patients with FNF

Among the 125 patients with FNFs, 56 (44.80%) exhibited anxiety, with a mean SAS score of 47.61 ± 8.81; 50 patients (40.00%) showed depressive symptoms, averaging 50.96 ± 6.2 on the SDS. Additionally, 18 patients (14.40%) had both anxiety and depression (Figure 2).

Figure 2 Psychological assessment of 125 femoral neck fracture patients. A: Anxiety prevalence; B: Depression incidence.

Pain intensity assessment in patients with anxiety/depression

Patients were grouped into anxiety (n = 56) vs non-anxiety (n = 69) and depression (n = 50) vs non-depression (n = 75) subgroups. VAS scores were significantly higher in both anxiety and depression groups compared with their respective controls (P < 0.01) (Figure 3).

Figure 3 Pain assessment in anxiety/depression patients. A: Visual Analogue Scale (VAS) score comparison between anxiety (n = 56) and non-anxiety (n = 69) groups; B: VAS score comparison between depressed (n = 50) and non-depressed (n = 75) patients. ^aP < 0.05. ^bP < 0.01. VAS: Visual Analogue Scale.

Overall comfort of patients with anxiety/depression

GCQ assessment showed that the anxiety and depression groups had markedly lower comfort scores than their corresponding control groups (P < 0.01) (Figure 4).

Figure 4 Comfort levels in anxiety/depression patients. A: General Comfort Questionnaire (GCQ) score comparison between anxiety (n = 56) and non-anxiety (n = 69) groups; B: GCQ score comparison between depression (n = 50) and non-depression (n = 75) groups. ^bP < 0.01. GCQ: General Comfort Questionnaire.

Postoperative recovery in patients with anxiety/depression

Harris and ADL evaluations indicated poorer postoperative recovery in patients with anxiety or depression than in those without these conditions (P < 0.01) (Figure 5).

Figure 5 Postoperative recovery in patients with or without anxiety/depression. A: Harris scores in the anxiety group (n = 56) vs non-anxiety group (n = 69); B: Harris scores in the depression group (n = 50) vs non-depression group (n = 75); C: Activities of Daily Living Scale (ADL) scores in the anxiety group (n = 56) vs non-anxiety group (n = 69); D: ADL scores in the depression group (n = 50) vs non-depression group (n = 75). ^bP < 0.01. ADL: Activities of Daily Living Scale.

Correlation of anxiety with pain, comfort, and postoperative recovery

Correlation analyses showed that SAS was positively correlated with VAS (r = 0.311, P < 0.001) but negatively corelated with GCQ (r = -0.250, P = 0.005), Harris (r = -0.249, P = 0.005), and ADL (r = -0.322, P < 0.001) (Table 1).

Table 1 Correlation of anxiety with pain, comfort, and postoperative recovery.

Correlation		VAS	GCQ	Harris	ADL
SAS	r value	0.311	-0.250	-0.249	-0.322
	P value	< 0.001	0.005	0.005	< 0.001

VAS: Visual Analog Scale; GCQ: General Comfort Questionnaire; ADL: Activities of Daily Living Scale; SAS: Self-Rating Anxiety Scale.

Impact of depression on pain, comfort, and postoperative recovery

Higher SDS scores were significantly correlated with increased VAS scores (r = 0.291, P < 0.001) and decreased GCQ, Harris, and ADL scores (r = -0.353, P < 0.001; r = -0.330, P < 0.001; r = -0.389, P < 0.001) (Table 2).

Table 2 Impact of depression on pain, comfort, and postoperative recovery.

Correlation		VAS	GCQ	Harris	ADL
SDS	r value	0.291	-0.353	-0.330	-0.389
	P value	< 0.001	< 0.001	< 0.001	< 0.001

VAS: Visual Analog Scale; GCQ: General Comfort Questionnaire; ADL: Activities of Daily Living Scale; SDS: Self-Rating Depression Scale.

DISCUSSION

In this analysis of 125 FNF cases, anxiety, depression, and combined anxiety-depression were observed in 44.80%, 40.00%, and 14.40% of the patients, respectively, mostly at mild levels. These findings align with those of Chen et al[17], who reported anxiety rates of 5.0%-40.0% and depression rates of 22.0%-88.0% in elderly orthopedic trauma patients. Patients with anxiety or depression demonstrated greater pain intensity (higher VAS score), lower overall comfort (lower GCQ score), and lower postoperative recovery (lower Harris and ADL scores). Providing high-quality nursing care for FNF patients with psychological distress may help reduce stress, alleviate pain, improve overall comfort, and support smoother postoperative recovery. Potential mechanisms may involve neuroinflammation and microglial activation, modulating the anxiety-depression-pain axis[18]. Prior studies have recommended perioperative positioning guidance, maintaining clean and well-ventilated environments, individualized functional exercise programs (e.g., Otago), educational and psychological support, and tailored analgesia strategies as intervention measures. Implementing such measures can promote comprehensive recovery and improve both emotional and physical outcomes[19-21]. In clinical practice, establishing integrated psychiatric screening for FNF may enable early identification and intervention for anxiety and depression. Additionally, cognitive behavioral therapy may help mitigate “pain catastrophizing” and improve prognoses from both preventive and therapeutic perspectives.

Through correlation analysis, anxiety or depression in patients with FNF showed a weak positive correlation with pain and a weak negative correlation with overall comfort and postoperative recovery. These findings indicate a potential association between psychological status and pain, overall comfort, and postoperative recovery outcomes in FNF. Simske et al[22] similarly reported that psychiatric comorbidities increased pain severity and worsened functional outcomes after ankle fractures, aligning with our observations despite differing patient groups. Jiang et al[23] also noted that FNF-induced pain can trigger discomfort and depression in patients, with pain intensity predicting the duration of depressive symptoms, complementing our results. In the study by Gudmundsson et al[24], functional improvement was negatively correlated with pain catastrophizing, anxiety, and depression in patients with hip pathology, and improved hip function reduced these negative emotions, supporting our findings. Prior studies likewise show that depressive symptoms and catastrophic thinking can weaken the relationship between fracture severity and functional impairment, suggesting psychological status acts as a modifier in recovery assessments, consistent with our data[25]. Additional evidence indicates that thoracolumbar fractures in young patients often cause anxiety and depression, increasing social burdens and delaying recovery; strengthened social support may reduce psychological distress and promote rehabilitation, which is in agreement with our results[26]. Regarding the potential causal relationship between psychological distress in patients with FNF and their overall comfort, these factors may influence each other: Negative emotions may heighten perceived discomfort, while better comfort may help reduce psychological distress.

This study has several limitations: First, using a single cut-off value to categorize anxiety and depression may mask differences across mild, moderate, and severe symptoms, future work should stratify by severity or apply trend analyses. Second, the research design, limited sample size, and single-center setting may introduce bias; prospective or interventional studies are needed to validate the findings. Third, the causal direction relationship between anxiety or depression and pain, overall comfort, and postoperative recovery in patients with FNF remains unclear; randomized controlled trials are required to determine causality. Lastly, potential confounders such as fracture type, surgical method, anesthesia strategy, comorbidities, and social support were not considered; future multivariable regression analyses should address these factors to more accurately assess the independent effect of psychological distress on clinical outcomes.

CONCLUSION

In summary, anxiety or depression typically mild was common among the 125 patients with FNF and was associated with heightened pain sensitivity, reduced overall comfort, and poorer postoperative functional outcomes. Both anxiety and depression showed weak correlations with pain severity, overall comfort, and rehabilitation outcomes. These results highlight the importance of psychological status in FNF recovery and support incorporating systematic psychological assessment and intervention into routine orthopedic care, offering meaningful clinical value.