Influence of mental and psychological states on surgical outcomes following open reduction and internal fixation for trimalleolar ankle fractures

Table 1 Baseline data of patients, mean ± SD/median (interquartile range)

Variables	Group A (n = 231)		Group B (n = 236)		t/Z/χ2	P value	Group difference (95%CI)	Effect size (95%CI)
	Male	Female	Male	Female
Sex	79 (34.20)	152 (65.80)	136 (57.63)	100 (42.37)	-5.07	< 0.01
Age (years)	43.00 (32.00, 57.00)		40.50 (31.00, 59.00)		-0.18	0.86	Med diff: -3.00 (-3.00 to 0.00)	r: -0.01 (-0.01 to 0.00)
BMI (kg/m2)	23.07 ± 3.49		23.45 ± 3.13		-1.25	0.21	MD: -0.38 (-0.99 to 0.22)	Cohen’s d: -0.12 (-0.30 to 0.07)
Follow-up time (months)	43.00 (32.00, 60.00)		43.50 (35.00, 60.00)		0.70	0.48	Med diff: -1.00 (-4.00 to 2.00)	r: 0.03 (-0.06 to 0.13)
Preoperative VAS	63.00 (55.00, 70.00)		57.00 (49.00, 66.00)		-4.31	< 0.01	Med diff: 5.00 (3.00-8.00)	r: -0.20 (-0.30 to -0.10)
Preoperative HADS-A	8.00 (7.00, 9.00)		5.00 (4.00, 6.00)		-16.90	< 0.01	Med diff: 3.00 (3.00-4.00)	r: -0.78 (-0.83 to -0.72)
Preoperative HADS-D	7.00 (7.00, 9.00)		5.00 (3.00, 5.00)		-17.40	< 0.01	Med diff: 4.00 (4.00-4.00)	r: -0.80 (-0.85 to -0.75)

CI: Confidence interval; BMI: Body mass index; VAS: Visual Analogue Scale; HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; Med diff: Median difference; MD: Mean difference; r: Rank-biserial correlation.

Table 2 Distribution of preoperative psychological symptoms in group A patients

Psychological states	n (%)
Anxiety only (HADS-A ≥ 8, HADS-D < 8)	47 (20.35)
Depression only (HADS-D ≥ 8, HADS-A < 8)	62 (26.84)
Both anxiety and depression (both ≥ 8)	122 (52.81)
Total	231 (100)

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression.

Table 3 Multivariable linear regression analysis of factors associated with postoperative outcomes

Outcome	Variable	β (95%CI)	Standardized β	P value
Postoperative VAS
	Group (anxiety/depression vs control)	8.48 (5.17-11.79)	0.28	< 0.01
	Preoperative VAS	0.21 (0.12-0.30)	0.22	< 0.01
	Sex (female vs male)	2.18 (-0.84 to 5.20)	0.06	0.16
	Age	-0.03 (-0.08 to 0.02)	-0.05	0.24
	BMI	0.12 (-0.15 to 0.39)	0.04	0.39
	Follow-up time	-0.01 (-0.04 to 0.02)	-0.02	0.60
Postoperative AOFAS
	Group (anxiety/depression vs control)	-3.12 (-4.79 to -1.45)	-0.19	< 0.01
	Preoperative AOFAS	0.18 (0.09-0.27)	0.16	< 0.01
	Sex (female vs male)	-1.40 (-3.13 to 0.33)	-0.07	0.11
	Age	0.01 (-0.03 to 0.05)	0.02	0.65
	BMI	-0.08 (-0.28 to 0.12)	-0.04	0.44
	Follow-up time	0.02 (-0.01 to 0.05)	0.04	0.31
Postoperative CSI
	Group (anxiety/depression vs control)	2.92 (1.89-3.95)	0.37	< 0.01
	Preoperative VAS	0.08 (0.04-0.12)	0.22	< 0.01
	Sex (female vs male)	0.43 (-0.60 to 1.46)	0.05	0.41
	Age	-0.01 (-0.04 to 0.02)	-0.04	0.55
	BMI	0.05 (-0.08 to 0.18)	0.04	0.45
	Follow-up time	-0.01 (-0.03 to 0.01)	-0.03	0.49
Postoperative EQ-5D-5 L
	Group (anxiety/depression vs control)	-3.38 (-4.81 to -1.95)	-0.25	< 0.001
	Preoperative VAS	-0.12 (-0.19 to -0.05)	-0.18	< 0.001
	Sex (female vs male)	-0.82 (-2.32 to 0.68)	-0.05	0.28
	Age	0.02 (-0.01 to 0.05)	0.05	0.21
	BMI	-0.06 (-0.22 to 0.10)	-0.04	0.46
	Follow-up time	0.01 (-0.01 to 0.03)	0.02	0.53

CI: Confidence interval; BMI: Body mass index; VAS: Visual Analogue Scale; AOFAS: American Orthopaedic Foot & Ankle Society Forefoot Score; CSI: Central Sensitization Inventory; EQ-5D-5 L: EuroQol Five Dimensions Five Levels.

Table 4 Comparison between the two patient groups before the operation and at the last follow-up, median (interquartile range)

Variables		Pairing		Z	P value	Group difference (95%CI)	Effect size (95%CI)
		Preoperative	Last follow-up
Group A (n = 231)	VAS; HADS-A; HADS-D	63.00 (55.00, 70.00)	19.00 (12.00, 24.00)	-13.18	< 0.01	Med diff: 44.00 (42.00-46.00)	r: -0.61 (-0.55 to -0.66)
		8.00 (7.00, 9.00)	3.00 (3.00, 5.00)	-13.20	< 0.01	Med diff: 4.00 (4.00-5.00)	r: -0.61 (-0.66 to -0.56)
		7.00 (7.00, 9.00)	5.00 (3.00, 7.00)	-13.16	< 0.01	Med diff: 4.00 (3.00-4.00)	r: -0.61 (-0.65 to -0.56)
Group B (n = 236)	VAS; HADS-A; HADS-D	57.00 (49.00, 66.00)	8.00 (5.00, 12.00)	-13.32	< 0.01	Med diff: 48.00 (47.00-50.00)	r: -0.62 (-0.66 to -0.57)
		5.00 (4.00, 6.00)	2.00 (1.00, 2.00)	-13.29	< 0.01	Med diff: 3.00 (3.00-3.00)	r: -0.62 (-0.66 to -0.58)
		5.00 (3.00, 5.00)	1.00 (1.00, 2.00)	-12.82	< 0.01	Med diff: 3.00 (3.00-3.00)	r: -0.59 (-0.63 to -0.55)

CI: Confidence interval; VAS: Visual Analogue Scale; HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; Med diff: Median difference; r: Rank-biserial correlation.

Table 5 Comparison of postoperative outcomes across psychological states in subgroups, median (interquartile range)

Outcome	Anxiety only (n = 47)	Depression only (n = 62)	Both (n = 122)	P value
Postoperative VAS	15.0 (10.0, 20.0)	18.0 (12.0, 23.0)	21.0 (14.0, 26.0)	< 0.01
Postoperative AOFAS	95.0 (92.0, 98.0)	93.0 (90.0, 96.0)	91.0 (88.0, 95.0)	< 0.01
Postoperative CSI	5.0 (4.0, 7.0)	6.0 (4.0, 8.0)	8.0 (6.0, 10.0)	< 0.01
Postoperative EQ-5D-5 L	94.0 (91.0, 97.0)	92.0 (89.0, 95.0)	90.0 (87.0, 93.0)	< 0.01

VAS: Visual Analogue Scale; AOFAS: American Orthopaedic Foot & Ankle Society Forefoot Score; CSI: Central Sensitization Inventory; EQ-5D-5 L: EuroQol Five Dimensions Five Levels.

Table 6 Comparison of evaluation indicators at the last follow-up between the two groups of patients, median (interquartile range)

Variables	AOFAS	VAS	HADS-A	HADS-D	CSI	EQ-5D-5 L
Group A (n = 231)	93.00 (90.00, 97.00)	19.00 (12.00, 24.00)	3.00 (3.00, 5.00)	5.00 (3.00, 7.00)	7.00 (5.00, 9.00)	92.00 (89.00, 95.00)
Group B (n = 236)	97.00 (94.00, 98.00)	8.00 (5.00, 12.00)	2.00 (1.00, 2.00)	1.00 (1.00, 2.00)	4.00 (3.00, 6.00)	97.00 (94.00, 99.00)
Z	-9.48	-12.92	-14.48	-14.98	-11.25	11.73
P value	< 0.01	< 0.01	< 0.01	< 0.01	< 0.01	< 0.01
Group difference (95%CI)	Med diff: -4.00 (-4.00 to -3.00)	Med diff: 10.00 (9.00-11.00)	Med diff: 2.00 (2.00-2.00)	Med diff: 3.00 (3.00-3.00)	Med diff: 3.00 (2.00-3.00)	Med diff: -4.00 (-5.00 to -4.00)
Effect size (95%CI)	r: -0.40 (-0.45 to -0.35)	r: -0.54 (-0.58 to -0.50)	r: -0.60 (-0.64 to -0.56)	r: -0.61 (-0.65 to -0.57)	r: -0.47 (-0.51 to -0.43)	r: 0.48 (0.43-0.53)

CI: Confidence interval; VAS: Visual Analogue Scale; HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; AOFAS: American Orthopaedic Foot & Ankle Society Forefoot Score; CSI: Central Sensitization Inventory; EQ-5D-5 L: EuroQol Five Dimensions Five Levels; Med diff: Median difference; r: Rank-biserial correlation.

Table 7 Comparison of evaluation indicators at the last follow-up between the two patient groups, median (interquartile range)

Variables	Pain	Function	Alignment
Group A (n = 231)	40.00 (30.00, 40.00)	47.00 (44.00, 48.00)	10.00 (10.00, 20.00)
Group B (n = 236)	40.00 (40.00, 40.00)	48.00 (47.00, 50.00)	10.00 (10.00, 10.00)
Z	7.74	2.89	1.01
P value	< 0.01	< 0.01	0.31
Group difference (95%CI)	Med diff: 0.00 (-10.00 to 0.00)	Med diff: -1.0 (-2.0 to 0.0)	Med diff: 0 (0-10.0)
Effect size (95%CI)	r: 0.36 (0.27-0.44)	r: 0.13 (0.04-0.22)	r: 0.05 (-0.04 to 0.14)

CI: Confidence interval; Med diff: Median difference; r: Rank-biserial correlation.

Table 8 Comparison of changes in each evaluation index between the two groups of patients before surgery and at the last follow-up, mean ± SD/median (interquartile range)

Variables	VAS changes	HADS-A changes	HADS-D changes
Group A (n = 231)	41.85 ± 0.91	4.00 (3.00, 5.00)	3.00 (2.00, 4.00)
Group B (n = 236)	47.43 ± 0.84	3.00 (2.00, 4.00)	3.00 (2.00, 4.00)
t/Z	-4.34	-6.87	-4.70
P value	< 0.01	< 0.01	< 0.01
Group difference (95%CI)	MD: -5.58 (-8.02 to -3.13)	Med diff: 1.00 (1.00-1.00)	Med diff: 1.00 (0.00-1.00)
Effect size (95%CI)	Cohen’s d: -0.42 (-0.60 to -0.23)	r: -0.31 (-0.35 to -0.26)	r: -0.22 (-0.26 to -0.17)

CI: Confidence interval; VAS: Visual Analogue Scale; HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; Med diff: Median difference; r: Rank-biserial correlation; MD: Mean difference.

Table 9 Correlation between age and gender of group A patients and preoperative anxiety and depression

Variables		Anxiety	Depression
Age	r	0.00	0.02
	P value	0.98	0.74
Sex	r	-0.11	-0.22
	P value	0.10	0.00
BMI	r	0.01	-0.03
	P value	0.90	0.66

BMI: Body mass index.

Table 10 Correlation between the degree of improvement after surgery and preoperative anxiety and depression in group A patients

Variables		Anxiety	Depression
VAS changes	r	-0.17	-0.04
	P value	0.01	0.60
CSI	r	0.52	0.51
	P value	< 0.01	< 0.01
EQ-5D-5 L	r	-0.48	-0.57
	P value	< 0.01	< 0.01

VAS: Visual Analogue Scale; CSI: Central Sensitization Inventory; EQ-5D-5 L: EuroQol Five Dimensions Five Levels.