Twenty-Five Percent of Patients Undergoing Knee Arthroscopy Use Psychotropic Medications

Purpose

To estimate the prevalence of psychotropic medication (PTM) usage in patients undergoing knee arthroscopy and to identify knee pathologies associated with the use of PTMs.

Methods

A retrospective chart review was conducted. Subjects were identified using the billing database at a single institution. All eligible patients treated by 2 fellowship-trained orthopaedic sports medicine surgeons between 2017 and 2021 were analyzed; patients were included if they were at least 12 years old and had at least 6 months of documented follow-up. The following characteristics were gathered: age, sex, surgery laterality, ipsilateral knee surgery history, knee pathology, and use of PTMs if listed in patient charts within 6 months prior to surgery.

Results

Records from 1,000 arthroscopic knee surgical procedures were examined (399 female and 601 male patients). From 2017 to 2021, 245 patients (24.5%) were prescribed at least 1 psychotropic drug. Female patients took PTM drugs at higher rates than male patients (odds ratio, 1.92; 95% confidence interval, 1.42-2.60; P <.001). An examination of drug classes revealed 106 antidepressant prescriptions (35.2%), 77 sedative hypnotics (25.6%), 38 stimulants (12.6%), 6 antipsychotics (2.0%), and 74 anticonvulsants/mood stabilizers (24.6%). Patients taking PTMs had lower adjusted odds of presenting with anterior cruciate ligament injury compared with their peers not taking PTMs (adjusted odds ratio, 0.55; 95% confidence interval, 0.32-0.82; P =.003).

Conclusions

The rate of PTM usage among patients undergoing knee arthroscopy was 24.5% based on 5 years of records from 1 institution. Female patients had a higher frequency of PTM use compared with their male counterparts.

Clinical Relevance

PTM use is common among knee arthroscopy patients, with higher rates observed in female patients.

Psychotropic medication (PTM) usage has steadily increased in the United States since the 1990s. ^, In 2007, researchers at the Centers for Disease Control and Prevention reported that 10% of the adult population in the United States was taking at least 1 PTM. Over a decade later, the National Health Interview Survey found that this rate rose to 15.8% in 2019 and 16.5% in 2020. ^, This upward trajectory has been exacerbated by global events, most notably the COVID-19 pandemic. Time-series analysis of PTM prevalence has shown increased rates after the pandemic.

Despite the high frequency of PTM use among Americans, there is a paucity of literature regarding the rate of PTM usage among patients undergoing knee arthroscopy and the impact of taking these medications on postoperative outcomes. Identifying PTM usage is important for improving patient care not only because psychopathologies such as depression and post-traumatic stress disorder have been associated with higher pain levels at discharge, but also because PTMs may increase perioperative risk and worsen postoperative outcomes. ^,^, Specifically, anxiety and depression have been shown to increase the intensity of surgical pain, the risk of chronic postsurgical pain, and the risk of delirium. ^, A retrospective analysis of patients undergoing rotator cuff repair, conducted using the TriNetX database (Cambridge, MA), further supported these patterns: Antidepressant use is associated with higher odds of acute postoperative pain, emergency department visits, and revision surgery. Physiological mechanisms may explain these findings as medications such as tricyclic antidepressants, selective serotonin reuptake inhibitors, and monoamine oxide inhibitors interact with anesthesia, with effects ranging from abnormal bleeding to hypertensive crisis and arrhythmia. ^, Postoperatively, orthopaedic patients with mental health comorbidities also face higher rates of non-routine discharge, increased postoperative care costs, and higher rates of mortality. ^,

By means of retrospective health record review, previous studies have found that 48% of patients undergoing hip arthroscopy and 41.8% of patients undergoing shoulder arthroscopy use PTMs, as compared with a general population usage rate of 16.5%. ^,^, The purpose of this study was to estimate the prevalence of PTM usage in patients undergoing knee arthroscopy and to identify knee pathologies associated with the use of PTMs. We hypothesized that the proportion of patients undergoing knee arthroscopy who were taking PTMs prior to surgery would be comparable to the proportions reported in patients undergoing shoulder and hip arthroscopy.

Methods

A retrospective chart review was conducted using the billing database at a single institution after expedited approval was received from the institutional review board of the overseeing institution. Patients treated by 2 fellowship-trained sports medicine surgeons (M.K.M., W.H.) between 2017 and 2021 were analyzed. Patients were included if they met the following criteria: age of at least 12 years, any type of arthroscopic knee procedure, and at least 6 months of documented postoperative follow-up. Variables including year of surgery, age, sex, laterality of procedure, history of ipsilateral knee surgery, PTM usage, and knee pathology were collected from patient charts. Patients were considered to be taking PTMs if the medications were listed as active in the electronic medical record at any time 6 months prior to surgery.

PTMs were classified as (1) antidepressants/anxiolytics, (2) sedative hypnotics, (3) stimulants, (4) antipsychotics, and (5) anticonvulsants/mood stabilizers. Table 1 lists the 5 drug classes and individual drugs within each class. For patients taking multiple PTMs, each drug was recorded and the presence of multiple medications was noted. All data analysis was conducted using R statistical software, version 4.3.2 (The R Foundation for Statistical Computing, Vienna, Austria).

Table 1

Drug Classes and Individual Drugs Seen in Patient Charts

Drug Class	Subtypes
Antidepressants/anxiolytics	SSRIs: sertraline, fluoxetine, citalopram, escitalopram, paroxetine, fluvoxamine SNRIs: duloxetine, venlafaxine TCAs: amitriptyline, doxepin, nortriptyline Atypical antidepressants: bupropion, trazodone, vilazodone, mirtazapine
Sedative hypnotics	Benzodiazepines: alprazolam, diazepam, lorazepam, clonazepam, triazolam GABAergic drugs: topiramate, zolpidem, eszopiclone Barbiturates: butalbital, butabarbital
Stimulants	Amphetamines: mixed-amphetamine salts, lisdexamfetamine, amphetamine Other: dexmethylphenidate, methylphenidate
Antipsychotics	Atypical antipsychotics: aripiprazole, lurasidone Dopamine agonists: ropinirole Phenothiazine antipsychotics: prochlorperazine
Anticonvulsants/mood stabilizers	Anticonvulsants: pregabalin, gabapentin Antiepileptics: lamotrigine, oxcarbazepine, zonisamide, rufinamide Muscle relaxants: tizanidine, cyclobenzaprine Mood stabilizers: lithium, divalproex sodium

GABAergic, affective gamma-aminobutyric acid transmission; SNRI, selective norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

Results

Patient charts from 2017 to 2021 included 1,000 individual arthroscopic knee surgical procedures performed on 399 female patients (39.9%) and 601 male patients (60.1%). During this 5-year period, a total of 245 patients (24.5%) were taking at least 1 psychotropic drug, with 44 (4.4%) taking 2 or more drugs. In 2017, 43 patients (22.5%) were taking PTMs, compared with 57 (24.8%) in 2018, 59 (24.9%) in 2019, 39 (24.7%) in 2020, and 47 (25.5%) in 2021 ( Fig 1 ). Although there was an empirical increase in drug usage rates from 2017 to 2021, year-on-year differences in drug usage rates were not statistically significant per the Mann-Kendall test ( P =.22).

Image, AltText currently not available — Fig 1

From 2018 to 2021, 20 patients (10.5%) underwent repeated knee arthroscopy: 5 (13.2%) were taking PTMs, and 15 (11.3%) were not. Logistic regression, holding all other variables constant and using 2017 as the base year, revealed that PTM status in a patient undergoing knee arthroscopy was not significantly associated with the probability of repeated arthroscopy for 4 years after surgery ( P =.801).

A total of 128 female patients (32.1%) were found to use PTMs compared with 117 male patients (19.5%) ( Fig 2 ). The odds ratio was calculated to be 1.92 (95% confidence interval [CI], 1.42-2.60; P <.001) using logistic regression. Other variables including history of ipsilateral knee surgery ( P =.26) and laterality of surgery ( P =.33) were not found to be statistically associated with psychotropic drug usage. Besides patient sex, the only variable associated with an increased probability of PTM usage was age ( P <.001). Calculating the marginal effect of age, we observed that an increase in age by 10 years from the mean (34.1 years) was associated with an increase in the probability of PTM usage by 5.9%, holding all other variables constant at baseline.