The Impact of Anxiety and Depression on Postoperative Pain Management and Emergency Room Visits in Pediatric Patients With Surgically Treated Lower Extremity Fractures: A Propensity-matched Cohort Analysis.

Abstract

Background: Anxiety and depression (AD) are prevalent comorbidities in pediatric patients and may influence postoperative outcomes. The impact of AD on postoperative pain medication use and emergency room (ER) visits in children with surgically treated lower extremity fractures has not been well-documented. This study aimed to evaluate the association between AD and outpatient postoperative pain medication requirements as well as ER visits in this population.

Methods: A retrospective cohort study was conducted using electronic medical records from 2000 to 2023 in a large national database of health care organizations across the United States. Pediatric patients (age below 18) with surgically treated lower extremity fractures were included. Patients were categorized into 2 groups: those with AD and those without (No-AD). Patients were further dichotomized into 2 groups based on fracture location: femur (femur) versus tibia or ankle (tibia/ankle). Outcomes of interest included the use of intravenous (IV) opiates within 3 days postoperatively, the number of outpatient oral (PO) opiate prescriptions, and the proportion of patients with at least one ER visit within 1 year postsurgery. Hazard ratios (HRs) were calculated using Cox proportional hazard models, adjusting for demographic and clinical characteristics.

Results: A total of 25,658 patients with either femur or tibia/ankle fractures were included. After matching, 735 patients were included in the AD femur cohort, and 945 in the AD tibia/ankle cohort. Each cohort was matched 1:1 with their control counterparts. In the femur fracture cohort, 49.80% of AD patients and 46.53% of No-AD patients required IV opiates within the first 3 days after surgery (HR, 1.09; P=0.21). Outpatient PO opiate use was significantly higher in AD patients (55.78% vs. 38.50%, HR, 1.64; P<0.001). In addition, AD patients had a higher proportion of ER visits (20.3% vs. 11.7%, HR, 1.68; P<0.001). In the tibia/ankle fracture cohort, 55.2% of AD patients and 48.3% of No-AD patients required IV opiates within the first 3 days (HR, 1.18; P<0.001). Outpatient PO opiate use was also higher in AD patients (46.35% vs. 32.06%, HR, 1.55; P<0.001). ER visits were more frequent in AD patients (21.26% vs. 9.63%, HR, 2.08; P<0.001).

Conclusions: Pediatric patients with AD undergoing surgery for lower extremity fractures have increased postoperative pain medication requirements and higher rates of ER visits compared with those without AD. These findings highlight the need for targeted interventions, such as the use of preoperative counseling or multimodal pain regimens, to manage postoperative pain and reduce ER visits in this vulnerable population.

Level of evidence: Prognostic level III.