Number of Patient-Reported Allergies and Other Mental Health Measures Correlate With Symptom Severity at Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To determine whether patient-reported allergies (a proposed indirect measure of mental health) or direct measures of mental health are associated with preoperative symptom scores, as measured by the 12-item International Hip Outcome Tool (iHOT-12) in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome.

Methods

This retrospective study analyzed prospectively collected data from consecutive patients undergoing outpatient hip arthroscopy for femoroacetabular impingement syndrome by a single surgeon. Patients completed the iHOT-12 preoperatively. Number of allergies, medication classes with allergic reactions, and reaction types were documented. Mental health was assessed via pre-existing psychiatric diagnoses, EQ-5D-5L anxiety/depression score, and Mental Health Inventory-5 (MHI-5) score. Associations between mental health measures (including allergies) and iHOT-12 scores were determined using bivariate and multivariate regression with forward selection.

Results

Ninety-one patients were included (69.2% male, 30.8% female), with a mean age of 36.6 (±13.7) years. In bivariate analysis, mental health measures associated with lower iHOT-12 scores were number of allergies (−1.91 per allergy, SE = 0.62; P =.002), MHI-5 score (+0.87 per point, SE = 0.38; P =.03), EQ-5D-5L anxiety/depression score (−3.87 per point, SE = 1.71; P =.03), and nonphysiologically appropriate allergic reactions (−3.78 per reaction, SE = 1.72; P =.03). Independent predictors of iHOT-12 scores in multivariate analysis were number of allergies (−1.16 points per allergy, SE = 0.58; P =.04), EQ-5D-5L anxiety/depression score, (−3.68 per 1 point increase, SE = 1.51; P =.02), and UCLA activity score (2.83 per 1-point increase, SE = 0.71; P =.001).

Conclusions

Number of self-reported allergies is a simple, easily accessible measure that clinicians can use as a proxy measure of mental health that is predictive of patient-reported outcome measures prior to hip arthroscopy.

Level of Evidence

Level III, Retrospective cross-sectional.

Hip arthroscopy was first clinically described in 1939; however, its routine use for diagnosing and managing hip pathology did not gain traction until the 1980s. ^, While hip arthroscopy generally produces positive outcomes, failure rates are notable. A systematic review of mid- to long-term follow-up studies (5, 10, and 20 years) reported reoperation or conversion to total hip arthroplasty rates ranging from 2.4% to 41.0%. Another review reported a 5.5% reoperation rate at short-term follow-up (95% confidence interval: 3.6%, 0–7.5%).

Effective patient selection and appropriate surgical indications are critical to minimizing complications, optimizing outcomes, and managing patient expectations. Negative outcome predictors include osteoarthritis, older age, female sex, prolonged preoperative symptom duration, elevated body mass index (BMI), increased lateral center-edge angle, and labral debridement. ^,^, Additionally, mental health factors, such as anxiety and depression have been associated with worse surgical outcomes. ^, However, arthroscopic hip surgery for femoroacetabular impingement syndrome (FAIS) has been shown to significantly reduce depressive symptoms postoperatively.

While well-documented mental health predictors for surgical outcomes exist, the potential role of patient-reported allergies is largely overlooked. A study by Graves et al. demonstrated that having 4 or more reported allergies resulted in significantly worse physical function outcomes, demonstrating worse surgical outcomes in patients with more allergies. Existing literature presents conflicting findings: some studies report worse postoperative outcomes in patients with a higher number of reported allergies, while others observe no significant effect. ^,^,^,^,^,^,

Published literature has clearly documented the association between allergies and poor mental health outside the orthopedic field. ^,^,^,^, As such, the number of reported allergies could serve as a practical surrogate for assessing mental health status, which can, in turn, help predict outcomes and establish realistic patient expectations. Allergy history is universally collected during preoperative evaluations, whereas mental health history is often inconsistently documented depending on the setting. Although the relationship between allergies and poor mental health is well established, it has not been well studied with respect to FAIS or hip arthroscopy.

The purpose of this study was to determine whether patient-reported allergies (a proposed indirect measure of mental health) or direct measures of mental health are associated with preoperative symptom scores, as measured by the 12-item International Hip Outcome Tool (iHOT-12) in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. We hypothesized that patients reporting a greater number of allergies and worse mental health will exhibit worse preoperative symptoms, as measured by the iHOT-12.

Methods

Patients and Data Collection

This retrospective cross-sectional study collected data from consecutive hip arthroscopies performed by a single surgeon (J.S.E.) at an outpatient facility between June 11, 2024, and November 12, 2024. Institutional review board approval (IRB) was obtained from Indiana University (IRB protocol no. 22178, Indiana University Hip Preservation Outcomes Study [Retrospective Enrollment]; and protocol no. 22175, Indiana University Hip Preservation Outcomes Study). The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Patients were included in the study if they underwent hip arthroscopy for FAIS during the study timeframe. Patients were excluded if based on the following criteria: (1) aged <14 years or >60 years; (2) inability or unwillingness to complete survey at day of surgery; (3) inability to complete informed consent or complete the study in English; (4) current incarceration (prisoners, inmates, or pending conviction with incarceration; (5) or current pregnancy.

On the day of surgery, patients completed an unassisted preoperative multipart survey consisting of the following instruments: iHOT-12, Mental Health Inventory-5 (MHI-5), EuroQol 5-Dimension, 5-level questionnaire (EQ-5D-5L), and University of California, Los Angeles (UCLA) Activity Score. ^,^,^,^, Additionally, patients completed a general health and demographics form, which included self-reporting any allergies and psychological disturbances or diagnoses (e.g., anxiety, depression, ADHD). This form was reviewed with each patient by a preoperative nurse on the day of the surgery. These data were collected prospectively with no incomplete forms, resulting in 100% data capture among patients that met study inclusion criteria. A retrospective review of patient charts was conducted to identify any psychiatric diagnoses not reported by the patient during the preoperative survey.

Patient-reported allergies were documented individually by the medication name or allergen, along with the reported allergic response. These reported allergies were categorized into 4 groups: antibiotics, pain medications, other medications, or nondrug allergies. Allergic reactions were further categorized into 2 groups: true allergy/normal adverse reaction and abnormal/uncommon adverse reaction. An abnormal adverse reaction to a reported allergy was defined as any reported allergic reaction deviating from well-defined allergic manifestations of a particular medication or substance. This could include subjective or nonspecific symptoms that occur after exposure to an allergen but lack clear diagnostic markers or alignment with standard immune-mediated reaction types (type I-IV hypersensitivity) or alignment with common adverse drug reactions. Additionally, the total number of preoperative communications were documented. Preoperative anxiety is an important psychological factor to consider, and this may be manifested as a greater number of preoperative phone calls from patients. ^, This number was calculated with retrospective chart review by tallying each new conversation initiated by the patient via telephone or secure messaging systems within the electronic health record and patient portal systems. To qualify, communications had to occur after the patient’s final in-office clinical appointment but before surgery, excluding conversations strictly related to scheduling.

Statistical Analysis

Demographics were reported for 2 cohorts: patients who reported 0 allergies and those with 1 or more reported allergies. Comparisons between these cohorts were conducted using t tests for continuous variables, χ ² tests for categorical variables, and Kruskal–Wallis tests for variables with non-normal distributions. Number of reported allergies and other continuous measures of mental health were then individually assessed as a predictor of iHOT-12 scores with bivariate linear regression. A sensitivity analysis was performed by treating the number of allergies as a categorical variable with various cut points, with t tests used to compare mean iHOT-12 scores for patients with more and less than 1, 2, 3, 4, and 5 allergies, respectively. To assess for confounding of the relationship between number of allergies and symptom severity, a forward selection multivariable linear regression analysis was performed. All demographic and mental health measures were considered as covariates. Covariates were included in the model if they were independent predictors of iHOT-12 scores or resulted in a 20% or greater change in the β coefficient for the number of reported allergies as a predictor of iHOT-12 scores. All statistical analyses were conducted using JMP Pro 17.2.0, with p values <.05 considered statistically significant.

Results

Ninety-one patients who underwent hip arthroscopy were selected to be in this study. Most, 63 (69.2%) patients, were female, while 28 (30.8%) were male. The mean age of patients was 36.6 (±13.7) years. Basic demographics comparing patients who reported 0 allergies and patients with 1 or more reported allergies are listed ( Table 1 ). Females were represented significantly ( P =.014) more in the 1+ reported allergy cohort compared to those reporting 0 allergies. Additionally, patients reporting 1+ allergies had 1 ( P =.011) more pre-existing mental health diagnoses compared to those with 0 reported allergies. All other variables—age, race, ethnicity, iHOT-12, UCLA activity score, MHI-5, EQ-5D-5L, and preoperative communications—did not significantly differ between groups of 0 and 1+ allergies. At least 1 allergy (range: 1-15 allergies) was reported in 59 (64.8%) patients, while 32 patients (35.2%) did not report any allergies ( Fig 1 ). In total, 105 unique allergens were reported by the 59 patients who reported any allergies. Thirty-seven (40.7%) patients reported an allergy to at least 1 antibiotic, 18 (19.8%) patients reported an allergy to at least 1 pain medication, 30 (33.0%) patients reported an allergy to at least 1 medication other than antibiotic or pain medications, and 32 (35.2%) patients reported at least 1 nondrug allergy. In total, there were 20 different antibiotic allergies reported, 10 different pain medication allergies reported, 53 medication allergies reported that were not either a pain medication or antibiotic medication, and 22 different nondrug allergies reported. Bivariate regression analysis was performed, and the number of reported allergies resulted in the highest coefficient of determination ( R ² = 0.10) among all recorded mental health-related variables ( Table 2 ). For each additional reported allergy, it is predicted to decrease iHOT-12 scores by 1.91 points [standard error (SE) = 0.61; P =.002] on average. Additionally, MHI-5, EQ-5D-5L anxiety/depression dimension, and number of non-normal physiological allergic reactions demonstrated significant changes in predicted iHOT-12 scores. With a higher MHI-5 score indicating better mental health, each additional point scored on the MHI-5 questionnaire is predicted to increase iHOT-12 scores by 0.87 points (SE = 0.38; P =.026). Alternatively, a lower EQ-5D-5L anxiety/depression dimension score indicates better mental health and as such, for each additional point scored on the anxiety/depression dimension of the EQ-5D-5L questionnaire, it is predicted to decrease iHOT-12 scores by 3.87 points (SE = 1.71; P =.026). For each additional reported non-normal physiological allergic reaction, it is predicted to decrease iHOT-12 scores by 3.78 points (SE = 1.72; P =.030). No significant association was noted between iHOT-12 scores and either increasing number of pre-existing psychiatric diagnoses or number of preoperative communications.

Table 1

Patient Demographics

	Patients Reporting 0 Allergies (n = 32; 35.2%)	Patients Reporting ≥ 1 Allergy (n = 59; 64.8%)	P Value
Sex			.014
Male	15 (46.9%)	13 (22.0%)
Female	17 (53.1%)	46 (78.0%)
Age	38.4 ± 14.2	35.6 ± 13.4	.348
Race			.256
Black	3 (9.4%)	4 (6.8%)
White	27 (84.4%)	55 (93.2%)
Asian or Pacific Islander	1 (3.1%)	0 (0%)
Other	1 (3.1%)	0 (0%)
Ethnicity			.657
Hispanic	1 (3.1%)	1 (1.7%)
Not Hispanic	31 (96.9%)	58 (98.3%)
iHOT-12	35.62 ± 18.68	30.13 ± 17.66	.178
UCLA Activity Score	5.13 ± 2.61	4.47 ± 2.33	.244
MHI-5	23.63 ± 4.62	21.81 ± 4.96	.086
EQ-5D-5L	2.00 ± 0.95	2.41 ± 1.15	.074
Preoperative communications	1 (0, 2)	1 (0.2)	.396
Number of psychiatric diagnoses	1 (0,2)	2 (1, 2)	.011