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Journal of Orthopaedic Research

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• Open access
• Published: 03 September 2024

Prevalence, resources, provider insights, and outcomes: a review of patient mental health in orthopaedic trauma

• Sophia Scott   ORCID: orcid.org/0009-0009-1219-9997 1 , 2 ,
• Devon T. Brameier   ORCID: orcid.org/0000-0002-8221-1172 2 ,
• Ida Tryggedsson   ORCID: orcid.org/0000-0002-0335-4344 3 ,
• Nishant Suneja   ORCID: orcid.org/0000-0003-1608-159X 2 ,
• Derek S. Stenquist   ORCID: orcid.org/0000-0001-7271-5580 2 ,
• Michael J. Weaver   ORCID: orcid.org/0000-0003-1062-8144 2 &
• Arvind von Keudell   ORCID: orcid.org/0000-0002-3312-7556 2  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  538 ( 2024 ) Cite this article

Metrics details

This literature review examines the impact of orthopaedic trauma on patient mental health. It focuses on patient outcomes, available resources, and healthcare provider knowledge and education. Orthopaedic trauma represents a significant physical and psychological burden for patients, often resulting in long-term disability, pain, and functional limitations. Understanding the impact of orthopaedic trauma on patient mental health is crucial for improving patient care, and optimizing recovery and rehabilitation outcomes. In this review, we synthesize the findings of empirical studies over the past decade to explore the current understanding of mental health outcomes in patients with orthopaedic trauma. Through this analysis, we identify gaps in existing research, as well as potential avenues for improving patient care and mental health support for patients with severe orthopaedic injuries. Our review reveals the pressing need for collaboration between healthcare providers, mental health professionals, and social support systems to ensure comprehensive mental care for patients with traumatic orthopaedic injuries.

Introduction

Orthopaedic trauma refers to severe injuries involving the musculoskeletal system, including fractures, dislocations, and soft tissue injuries. These injuries often result from high-energy events such as motor vehicle accidents, falls, sports-related incidents, or workplace accidents. Orthopaedic trauma can have a profound impact on individuals, leading to significant physical impairment, functional limitations, pain, and long-term disability.

While the physical consequences of orthopaedic trauma are well-recognized, the importance of considering patient mental health in orthopaedic trauma care has gained less attention. It is now widely recognized that orthopaedic trauma can have profound psychological implications, affecting the mental well-being and overall quality of life of patients [ 13 , 33 ].

Purpose and methods

The purpose of this review is to explore the impact of orthopaedic trauma on patient mental health. By examining the existing body of research, we provide a comprehensive overview of the current understanding of patient mental health in orthopaedic trauma, highlighting the interplay between physical and mental well-being. We aim to contribute to the development of effective interventions, improved patient care, and enhanced overall outcomes for individuals experiencing orthopaedic trauma.

Search strategy and selection criteria

This systematic review was conducted to evaluate the impact of orthopaedic trauma on patient mental health, focusing on patient outcomes, available resources, and healthcare provider knowledge and education. The review followed the PICO framework to guide the search strategy:

P (Population) Patients who have experienced orthopaedic trauma.

I (Intervention) Various interventions addressing mental health outcomes post-orthopaedic trauma.

C (Comparison) Comparisons included between different interventions or no intervention.

O (Outcomes) Mental health outcomes such as anxiety, depression, PTSD, quality of life, and rehabilitation success.

We performed a comprehensive search across multiple databases, including PubMed, MEDLINE, Embase, and the Cochrane Library. Keywords and MeSH terms used in the search included “orthopaedic trauma”, “mental health”, “psychological outcomes”, “rehabilitation”, “anxiety”, “depression”, and “PTSD”. The search was restricted to articles published in English from January 2006 to December 2023.

Study selection

The inclusion criteria for selecting studies were:

Empirical studies involving patients with orthopaedic trauma.

Studies that reported on mental health outcomes post-trauma.

Randomized controlled trials (RCTs), cohort studies, case–control studies, and qualitative studies.

Studies published within the past two decades.

Exclusion criteria were:

Studies not involving human subjects.

Studies lacking data on mental health outcomes.

Studies published in languages other than English.

Two reviewers screened the titles and abstracts of identified articles. Full-text articles were retrieved for further assessment based on inclusion and exclusion criteria. Disagreements were resolved through discussion and consensus.

Thirty-four papers met our selection and are included in our review.

Data extraction and quality assessment

Data extraction was conducted independently by two reviewers using a standardized form. Extracted data included study characteristics (e.g., author, year, study design), patient demographics, type of orthopaedic trauma, mental health outcomes, and interventions used.

Data synthesis

A qualitative synthesis of the findings from included studies was performed to provide an overview of the impact of orthopaedic trauma on patient mental health.

Mental health outcomes in patients with orthopaedic trauma

Orthopaedic trauma can have a significant impact on the mental health and psychological well-being of patients. Understanding the prevalence of mental health disorders and the factors influencing these outcomes is crucial for providing comprehensive care and optimizing patient outcomes.

Overall prevalence

Numerous studies have reported a high prevalence of mental health disorders among orthopaedic trauma patients. For example, Alexiou et al. [ 1 ] conducted a review focusing on elderly patients after a hip fracture and found that up to 35% of these patients experience symptoms of depression and anxiety, leading to a significant decrease in their quality of life. Obey and Miller [ 19 ] highlighted that approximately 20% of orthopaedic trauma patients experience post-traumatic stress disorder (PTSD), which can have a profound impact on their psychological well-being. Bhandari et al. [ 2 ] conducted an observational study and found that nearly 60% of orthopaedic trauma patients experienced symptoms of psychological distress, with approximately 30% meeting the criteria for depression. They also reported that patients with higher levels of psychological distress had significantly lower scores in various domains of quality-of-life assessment. These findings emphasize the importance of recognizing and addressing the psychological needs of orthopaedic trauma patients. Care must include not only physical rehabilitation but also mental health support. Incorporating psychological interventions into orthopaedic trauma treatment plans can potentially improve patients’ well-being and overall outcomes.

Moreover, pandemic-related stressors further contributed to the psychological burden experienced by patients [ 24 ]. The stress induced by the pandemic appears to place individuals with mental illness at a heightened risk for perilous behaviors and subsequent fractures. Ohliger et al. [ 20 ] investigated the mental health of orthopaedic trauma patients during the COVID-19 pandemic and found that approximately 40% of patients reported increased levels of anxiety and depressive symptoms during this period. These findings suggest that the pandemic has exacerbated existing mental health challenges among orthopaedic trauma patients, including increased rates of depression, anxiety, and post-traumatic stress symptoms.

Crichlow et al. [ 6 ] investigated the relationship between physical injury and depression in orthopaedic trauma patients. The researchers enrolled 161 patients from orthopaedic trauma services and found that 45% of patients had clinically relevant depression, with a strong negative correlation between global disability (SMFA scores) and depression (BDI). Open fractures were identified as a factor impacting the presence of depression, with an odds ratio of 4.58. The study highlights a high prevalence of depression in orthopaedic trauma patients and emphasizes the correlation between global disability and depression, with open fractures increasing the risk. Furthermore, Stinner and Mir [ 26 ] found that orthopaedic trauma patients with pre-existing mental health conditions are at a higher risk of developing psychological complications. They reported that approximately 50% of patients with a history of mental health disorders experienced exacerbation of their symptoms following orthopaedic trauma. These studies underscore the importance of addressing the mental health needs of orthopaedic trauma patients, particularly during times of crisis and limited access to resources.

ACL injuries, hip fractures, and hip arthroscopy

Conley et al. [ 5 ] aimed to determine the prevalence of postoperative depression or anxiety in patients under 25 following Anterior Cruciate Ligament Reconstruction (ACLR). Utilizing the Truven Healthcare Marketscan database, the researchers identified 42,174 ACLR patients under 25 and categorized them based on preoperative, postoperative, or no depression/anxiety using ICD-9 codes. The findings revealed that 10.7% of patients experienced postoperative depression/anxiety after ACLR. Females exhibited nearly twice the prevalence compared to males (14.4% vs. 7.6%), despite similar rates of secondary ACLR. Those with postoperative depression/anxiety had a higher reoperation prevalence (18.8%) compared to those without (13.7%) or with pre-existing preoperative depression/anxiety (12.9%). Female sex and secondary ACL surgery were independently associated with an increased prevalence of postoperative depression/anxiety. The study underscores the need for heightened awareness regarding the elevated risk in females and individuals with secondary ACL surgery, emphasizing the importance of screening and potential mental health referrals in these populations within the orthopaedic community.

Heidari et al. [ 9 ] sought to assess the prevalence of depression in older individuals who experienced hip fractures, considering it as a common complication in this population. The meta-analysis included 27 studies with a combined sample size of 11,958, and data were collected until July 2019. The overall prevalence of depression in older people with hip fractures was estimated to be 23% (95% CI 0.18–0.29). Subgroup analyses based on study design, follow-up duration, type of fracture, and gender were conducted to explore sources of heterogeneity. The study revealed variations in depression prevalence across regions, with the lowest rate in Asia (0.19) and the highest in America (0.27). The findings underscored the significance of addressing mood disorders in older hip fracture patients, emphasizing the need for further research to develop effective strategies for prevention and treatment in this vulnerable population.

Martin et al. [ 15 ] conducted a cohort study on the impact of symptoms of depression on self-reported function, pain, and satisfaction in patients undergoing hip arthroscopic surgery. Among 781 patients from a multicenter hip arthroscopic surgery registry, 651 patients had 2-year outcome data. Patients completed the 12-item International Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and 12-item Short-Form Health Survey (SF-12) during surgery consent. Symptoms of depression were identified using SF-12 mental component summary (MCS) scores, with cutoff scores indicating symptoms of depression and severe depression. Martin et al. [ 15 ] found that patients with depression symptoms demonstrated lower initial iHOT-12 and VAS scores and continued to score lower at the 2-year follow-up for iHOT-12, VAS, and surgical satisfaction. The study concluded that a substantial number of patients undergoing hip arthroscopic surgery exhibited symptoms of depression, adversely affecting self-reported function, pain, and satisfaction both initially and at the 2-year follow-up. The findings suggest the importance of surgeons recognizing depression symptoms and understanding their impact on surgical outcomes.

Pharmacological insights

Musculoskeletal trauma is a persistent cause of disability, as its impact extends beyond physical recovery to lasting mental health issues and post-traumatic stress disorder (PTSD) symptomology in over 50% of victims [ 14 ]. These mental health challenges, spanning diverse patient profiles, independently predict unfavorable outcomes. However, limited access, high costs, and time-intensive nature of mental health care often hinder its utilization by the trauma population, placing the management burden on orthopaedic teams, who frequently serve as the sole point of contact for patients within the medical system.

Lossada-Soto et al. [ 14 ] launched a single-center, repeated measures, randomized controlled pilot study involving 100 orthopaedic trauma patients aged 18–85 years. In this exploratory clinical trial, they aim to establish a safe, feasible, and time-limited protocol for immediate (post-injury) fluoxetine treatment by orthopaedic and non-mental health care providers dealing with musculoskeletal trauma victims, and to preliminarily assess the protocol’s effects on PTSD symptomology and physical recovery in these patients. Subjects were randomized during their index hospitalization to either fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI) endorsed by the American Psychiatric Association for PTSD treatment, or calcium, chosen for its minimal side effects and bone-healing potential. Feasibility markers encompass recruitment, randomization, medical adherence, anti-depressant side effects, and fracture union rate. Subjects complete physical and mental health surveys at baseline, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. This novel study endeavors to proactively prevent symptom development from the time of injury, empowering surgeons to approach patient care more holistically.

The association between mental health, substance use disorders, and patient-reported outcomes has been established, but their specific impact on opioid demand in hip fracture surgery remains unclear despite the high prevalence of hip fractures in the United States. Cunningham et al. [ 7 ] studied the relationship between opioid demand and mental health risk factors in hip fracture surgery. Conducting a retrospective cohort study involving 40,514 patients undergoing surgical fixation of hip fractures, they found that 60.3% filled opioid prescriptions within 7 days pre-op to 1-year post-op, averaging 187.7 oxycodone 5-mg equivalents. Additionally, 41.1% filled two or more opioid prescriptions within the specified time frame. Age, pre-op opioid filling, depression, tobacco abuse, and drug abuse were identified as significant risk factors associated with increased perioperative opioid filling. Pre-op opioid filling emerged as the most influential factor in determining perioperative opioid demand [ 7 ].

The study highlights pre-op opioid filling and drug abuse as the primary mental health-related drivers contributing to increased perioperative opioid prescription filling. While depression, psychoses, alcohol abuse, and tobacco abuse had relatively minor effects on prescription filling, these findings aid in identifying patients at risk for heightened opioid demand. This identification could lead to targeted interventions, including counseling, alternative pain management strategies, and potential referrals to pain management specialists.

Mental health outcomes in patients with orthopaedic trauma are a significant concern. High rates of mental health disorders decreased quality of life, and psychological distress are common in this population. Factors such as injury severity, pain, disability, and psychosocial factors influence these outcomes. Recognizing and addressing the psychological impact of orthopaedic trauma is crucial for providing comprehensive care and improving patient well-being. These studies provide specific data points that highlight the prevalence of mental health disorders among orthopaedic trauma patients, including symptoms of depression, anxiety, and PTSD. They emphasize the negative impact of orthopaedic trauma on patients’ quality of life and the exacerbation of pre-existing mental health conditions. Understanding these factors is crucial for developing targeted interventions and resources to support the psychological well-being of orthopaedic trauma patients.

Resources and interventions for mental health support

Psychological interventions also play an important role in enhancing patient outcomes following orthopaedic trauma. Various forms of therapy, such as cognitive behavioral therapy (CBT), mindfulness, meditation, and relaxation training, have been shown to effectively address psychiatric disorders, including depression, anxiety, and PTSD, leading to sustained symptom improvement. These approaches can not only alleviate mental health issues, but also, they can contribute to better overall rehabilitation outcomes for orthopaedic patients.

Mazurek et al. [ 17 ] investigated the effectiveness of Virtual Reality (VR) therapy in alleviating symptoms of depression, anxiety, and stress in older adults who recently underwent arthroplasty surgery, while also exploring the impact of psychological improvements on functional outcomes. The study, utilizing a parallel group randomized controlled trial design, involved 68 osteoarthritis patients who underwent total hip or knee arthroplasty. The experimental group received eight VR therapy sessions during rehabilitation, while the control group received standard care. The experimental group demonstrated significant improvements in both psychological and functional areas compared to the control group. Results indicated a significant relationship between psychological progress and functional recovery, suggesting that psychological factors can serve as predictors for functional outcomes. The study concluded that VR therapy holds promise as a beneficial addition to the rehabilitation process for older adults’ post-hip and knee arthroplasty. However, further research is needed to determine the long-term advantages of integrating psychological interventions into standard rehabilitation practices.

Psychological treatments, encompassing cognitive behavioral therapy (CBT), mindfulness, meditation, and relaxation training, have proven effective in addressing psychiatric disorders such as depression, anxiety, and PTSD, offering enduring symptom improvement. CBT, grounded in principles acknowledging that psychological issues stem from faulty thinking or learned unhelpful behavior, targets both behavioral and thinking patterns. By teaching patients better coping strategies and altering reactions to trauma-related experiences, CBT aims to instill positive changes [ 19 ].

Supported by a systematic review of 15 randomized control trials, perioperative psychotherapy—including CBT and relaxation therapy—showed moderate-quality evidence in significantly reducing persistent postsurgical pain and physical impairment [ 31 ]. In orthopaedic trauma patients, CBT focuses on perception change post-trauma and controlled exposure to provocative stimuli. An RCT demonstrated significantly lower impact of event scores in patients receiving CBT after injury. However, challenges like cost, geographic limitations, and therapist availability may restrict treatment access. Online resources and mobile apps, such as One Mind PsyberGuide, offer alternatives, enhancing accessibility to evidence-based CBT interventions and contributing to improved mental health by reducing symptoms related to anxiety and depression [ 19 ].

Pain counseling and mind–body therapies have proven beneficial in managing chronic musculoskeletal pain populations [ 3 ]. This approach can be extended to trauma survivors grappling with substantial pain symptoms during their recovery. In the context of acute trauma care for hip fracture patients, regular counseling during hospitalization has demonstrated the potential to alleviate pain severity, mitigate sleep disturbances, and decrease the reliance on pain medication compared to those without counseling [ 8 ].

Mind–body techniques, such as mindfulness-based stress reduction incorporating meditation, body awareness, and yoga postures, as well as cognitive-behavioral therapy, modifying maladaptive behaviors and cognitive processes, have shown promise in reducing musculoskeletal pain. These therapeutic approaches can be delivered by therapists or through automated computer programs guiding users through program steps. While acute care pain counseling could likely benefit multitrauma patients and those with other fractures, this intervention awaits thorough examination. Additionally, a case series has indicated the potential effectiveness of hypnosis in pain control during recovery from multiple fractures. Implementing these techniques may empower patients to manage pain symptoms, enhancing self-efficacy and rehabilitation gains [ 28 ]. Further, rigorous, controlled comparative efficacy studies evaluating each coping skill’s effectiveness for pain management are crucial for both clinicians and patients.

Healthcare provider perspectives

Reichman et al. [ 23 ] conducted a qualitative study exploring the perspectives of 79 orthopaedic health care professionals, including surgeons, residents, and nurses, across three Level I Trauma Centers regarding integrated psychosocial care in orthopaedic settings. The researchers utilized the evidence-based Rainbow Model of Integrated Care framework for their analysis. The findings revealed that orthopaedic health care professionals identified various potential benefits associated with integrating psychosocial services across different dimensions of integration. These benefits encompass increased patient satisfaction with care, a reduced burden on medical providers in managing patient distress, and potential cost reductions in healthcare utilization. Simultaneously, the study identifies significant barriers to integration, such as the fast pace of clinic environments and existing mental health stigma [ 23 ].

To address these barriers, the health care professionals provided recommendations across multiple dimensions of integration. Despite recognizing the potential benefits, the study emphasizes the need to tackle challenges and barriers to fully realize the advantages of integrated psychosocial care in orthopaedic trauma settings. The insights gathered from this study contribute valuable information for the development and implementation of initiatives aimed at integrating psychosocial services within orthopaedic settings, potentially improving patient recovery and long-term physical and mental health outcomes.

Given the considerable impact of mental and social health on the intensity of symptoms and the extent of limitations, Matkin and Ring [ 16 ] argue that efforts to enhance value in orthopaedic trauma should prioritize emotional and social recovery. Interventions with low value and potential harm, such as excessive reliance on medication, surgeries for “delayed healing” or “symptomatic implants”, repeated physical therapy visits, and other biomedical approaches, often indicate misdiagnosis and mismanagement of social and mental health aspects. A more effective approach involves anticipating emotional and social recovery, engaging mental health specialists immediately after injury, and formulating strategies that establish clear boundaries on biomedical tests and treatments unlikely to contribute to health, thereby avoiding the reinforcement of stress, distress, and less effective coping strategies.

Implications for clinical practice

Effective assessment of patient expectations is crucial in clinical orthopaedic research, particularly in the context of orthopaedic trauma surgery outcomes. Suk et al. [ 27 ] aimed to explore the alignment between patient expectations before surgery and the actual outcomes after surgical treatment for ankle fractures. Prospective recruitment of patients (≥ 18 years) with surgical ankle fractures was conducted at five orthopaedic trauma clinics in the United States (USA), Canada, and Brazil. A validated trauma expectation factor (TEF) questionnaire was administered before surgery, and a trauma outcome measure (TOM) was conducted one year post-surgery.

Among the 155 patients with complete records at one year, Suk et al. [ 27 ] found that nearly half (49%,76/155) achieved or exceeded their preoperative TEF score in the 1-year TOM assessment (95% CI 41–57%). Regional variations were observed, with TOM scores meeting or surpassing expectations for 33% of patients in the USA, 47% in Canada, and notably, 69% in Brazil ( p  = 0.001 (USA); p  = 0.024 (Canada)). This geographical disparity was attributed to higher initial patient expectations in North America compared to Brazil (average TEF scores: 36 (North America) versus 31 (Brazil); p  < 0.001). Patients with lower household income or those who smoked were more likely to report satisfaction with their treatment ( p  = 0.02 and p  = 0.05, respectively). Additionally, patients with severe type C fractures exhibited higher rates of satisfaction (62%) compared to simpler B (50%) or type A fractures (33%) ( p  = 0.01 [C type versus A type]).

Suk et al’s. [ 27 ] findings reveal challenges for orthopaedic surgeons in meeting or surpassing presurgical patient expectations regarding long-term outcomes for ankle fracture surgery. The results of their study underscore the substantial impact of culture, geography, and effective surgeon–patient communication on shaping patient expectations.

The Patient-Reported Outcomes Information System (PROMIS®) is increasingly employed in medical literature for patients with orthopaedic fractures. However, numerous studies have examined heterogeneous groups with chronic orthopaedic conditions, incorporating fracture patients. Houwen et al. [ 11 ] conducted a systematic review of PROMIS health domains, encompassing physical, mental, and social health, in patients experiencing orthopaedic fractures. PROMIS Physical Function (n = 32, 62.7%) and PROMIS Pain Interference (n = 21, 41.2%) were the most frequently utilized questionnaires. In contrast, PROMIS measures related to social (n = 5/51, 9.8%) and mental health (n = 10/51, 19.6%) were less commonly employed as outcome measures in the fracture population. Houwen et al. [ 11 ] identified a gradual increase in the use of PROMIS questionnaires in the orthopaedic fracture population since 2017.

The review revealed a diverse array of PROMIS measures across various domains in articles involving orthopaedic fracture patients. While PROMIS Physical Function and Pain Interference were prominent, the study underscores the importance of recognizing other health domains such as mental and social health as crucial aspects for fracture patients.

While the negative impact of poor preoperative mental health on postoperative satisfaction in spine surgery patients is established, limited evidence exists on the influence of postoperative mental health on satisfaction. Rahman et al. [ 22 ] conducted a retrospective review of prospectively collected data to evaluate the correlation between preoperative and postoperative mental health status and postoperative satisfaction in patients undergoing lumbar degenerative surgery. Adults undergoing lumbar degenerative surgery at a single institution were included.

The study included 183 patients (47% male; avg. age, 62 years). Preoperative depression was present in 27%, and postoperative depression was 29%, while preoperative anxiety was reported in 50%, decreasing to 31% postoperatively. 19 percent reported postoperative dissatisfaction. Preoperative and postoperative anxiety, and preoperative depression, did not correlate with postoperative satisfaction. Ultimately, Rahman et al. [ 22 ] found that patients undergoing lumbar degenerative surgery with postoperative depression, regardless of preoperative depression status, have significantly higher odds of dissatisfaction. These findings underscore the importance of postoperative depression screening and treatment in enhancing satisfaction for spine surgery patients.

Stinner and Mir [ 26 ] highlight the impact of patient mental health and well-being on orthopaedic trauma outcomes. The authors emphasize that psychological factors can significantly influence the overall recovery and functional outcomes of patients with orthopaedic trauma. The article discusses the potential effects of mental health conditions, such as depression, anxiety, and post-traumatic stress disorder (PTSD), on treatment adherence, rehabilitation progress, and overall patient satisfaction. The authors emphasize the importance of recognizing and addressing the psychological aspects of care to optimize orthopaedic trauma outcomes and promote the well-being of patients.

Vincent et al. [ 30 ] examined the effects of orthopaedic trauma on psychological distress, potential interventions for distress reduction, and the implications for rehabilitation participation. Survivors often grapple with post-traumatic stress syndrome, depression, and anxiety, hindering functional gains and diminishing quality of life. Early identification of distress allows care teams to provide necessary resources and support. Short-term recovery strategies encompass holistic approaches, pastoral care, coping skills, mindfulness, peer visitation, and educational resources. They concluded that long-term well-being is fostered by connecting survivors to supportive networks, facilitating support groups, and leveraging social support networking like The Trauma Survivors Network Vincent et al. [ 30 ]. Rehabilitation specialists play a pivotal role in optimizing patient outcomes and quality of life by actively participating in and advocating for these strategies.

A rotator cuff case study

Okafor et al. [ 21 ] conducted a study investigating the relationship between psychological distress, rotator cuff tear (RCT) severity, and patient-reported outcomes (PROs) in individuals undergoing arthroscopic rotator cuff repair. Their research aimed to assess differences in shoulder pain, function, and pain-associated psychological distress across varying RCT severities and determine whether psychological distress remains associated with shoulder outcomes when adjusting for tear severity.

Including 84 patients categorized into three groups based on RCT severity: partial-thickness, small-to-medium full-thickness, and large-to-massive full-thickness tears, they found no significant differences in PROs and psychological distress among the three RCT severity cohorts. However, significant associations are found between psychological distress and PROs. Notably, fear-avoidance behavior within the negative coping domain shows the strongest correlation with PROs, including fear avoidance for physical activity and work. Other dimensions within negative coping, negative mood, and positive coping also demonstrate significant associations with PROs [ 21 ].

These findings suggest that, in the context of arthroscopic rotator cuff repair, preoperative psychological distress may exert a more substantial influence on patient perceptions of shoulder pain and reduced shoulder function than the severity of the rotator cuff tear itself. These findings emphasize the importance of considering psychological factors in the assessment and management of patients undergoing such procedures.

Cho et al. [ 4 ] conducted a prospective study to investigate changes in psychological status (depression, anxiety, insomnia) and health-related quality of life (HRQoL) following rotator cuff repair. Forty-seven patients undergoing the procedure completed various assessments before surgery and at 3, 6, and 12 months postoperatively. Results revealed that depression, anxiety, and insomnia decreased after surgery, accompanied by an increase in quality of life. Scores for the Hospital Anxiety and Depression Scale (HADS) and the Pittsburgh Sleep Quality Index (PSQI) significantly decreased over the 12-month period. Quality of life, assessed by the World Health Organization Quality-of-life Scale Abbreviated Version (WHOQOL-BREF), showed a notable improvement.

At 12 months post-surgery, there were decreased prevalence rates of depression, anxiety, and insomnia compared to preoperative levels. Notably, preoperative depression, anxiety, and insomnia scores did not correlate with postoperative clinical outcomes, including the visual analog scale (VAS) pain score, UCLA Scale, and American Shoulder and Elbow Surgeons' Scale (ASES) at the 12-month mark.

Ultimately, the study suggests that successful rotator cuff repair is associated with improved psychological status and HRQoL, highlighting the positive impact of the surgery on patients' well-being. Furthermore, preoperative depression, anxiety, and insomnia did not serve as predictors of poor outcomes, underscoring the potential benefits of rotator cuff repair on both physical and psychological aspects in patients.

Outcomes and long-term consequences

Given the high prevalence of psychiatric disorders, particularly anxiety and depression, among orthopaedic trauma patients, Weinerman et al. [ 32 ] carried out a narrative review exploring the impact of anxiety and depression on outcomes in orthopaedic trauma surgery. The bidirectional relationship between chronic pain and mental health disorders is prevalent, with anxiety and depression identified as predictors of negative surgical outcomes. Screening tools such as PHQ-9, GAD-7, and SF-36 can assess mental health status and guide interventions. Adverse mental health outcomes are associated with factors like psychological distress, chronic pain, and traumatic limb amputation [ 32 ]. Opioid use for pain management is common but may worsen depression symptoms, suggesting the potential benefits of non-opioid pain management strategies [ 32 ]. The review underscores the importance of mental health interventions, both preoperative and postoperative, to optimize surgical outcomes and enhance the overall quality of life for orthopaedic trauma patients.

Holtslag et al. [ 10 ] conducted a prospective cohort study to elucidate the long-term functional repercussions of major trauma and quantify the influence of sociodemographic, injury-related, and physical determinants on outcomes. Assessing severely injured adult trauma survivors (n = 359) between 12- and 18-months post-trauma, the study utilized measures including the Glasgow Outcome Scale (GOS), EuroQol (EQ-5D), and cognitive complaints. Results from 335 participants revealed below-norm scores in various domains, with 48% reporting mobility limitations, 55% facing challenges in daily activities, and 65% experiencing cognitive complaints. Multivariate analyses identified injury localization (spinal cord, lower extremity, or brain), educational level, and comorbidity as significant predictors of long-term functional consequences. These results showcase the importance of considering these determinants in both outcome research and clinical practice to better understand and address the enduring impact of major trauma.

Future research

Future research should address several gaps in the understanding of the orthopedic trauma population. The prevalence of tobacco and substance use, along with symptoms of anxiety and depression, among the orthopaedic trauma population has not been extensively explored, despite their significant implications for surgical recovery. McCrabb et al. [ 18 ] carried out a cross-sectional study to elucidate the rates of these symptoms and substance use, make comparisons between smokers and non-smokers, and investigate the associations between symptoms, substance use, and smoking status. Surveying 819 orthopaedic trauma patients in two Australian public hospitals revealed that 21.8% were current smokers, 51.8% engaged in hazardous alcohol consumption in the past 12 months, and approximately 10% reported recent cannabis use or symptoms of anxiety/depression. Among current smokers, 21.8% also engaged in heavy drinking and recent cannabis use. Factors such as male gender, lower educational attainment, unmarried status, recent cannabis use, and heavy alcohol consumption were identified as correlates of current smoking. These findings underscore the need for future research to illuminate potential health behavior interventions targeting comorbidities within the orthopaedic trauma population, given the apparent substantial prevalence and potential impact on recovery.

Tøien et al. [ 29 ] conducted a prospective single-center study to investigate the proportion of patients returning to work and predictors of returning to pre-injury levels of work participation within the first year after trauma. The study, conducted in a trauma referral center, included 188 patients aged 18–65 years with varying degrees of injury severity. The assessments were initiated a median of 27 days after discharge, with follow-ups at 3 and 12 months. Results revealed that 70% of patients returned to the same level of work or education after one year, with 50% returning at 3 months. Predictors of return to work after 3 months included low age, low Injury Severity Score (ISS), absence of ventilator treatment, and low depression symptoms. At 12 months, low ISS, absence of serious head injury, low depression score, and an optimistic life orientation were significant predictors. Additionally, good physical function at 3 months independently predicted return to work at 12 months for those who had not returned at 3 months. These findings suggest screening for depression symptoms and pessimism, with intervention or treatment for those in need, to facilitate early return to work among trauma patients.

While this study provides valuable insights into the predictors of return to work after trauma, several gaps in existing research merit attention. First, the study focused on a single-center setting, potentially limiting the generalizability of its findings to broader populations. A more diverse and multicenter approach could enhance the external validity of the results. Additionally, the study mainly utilized self-report questionnaires to assess variables like anxiety, depression, and post-traumatic stress symptoms. Incorporating objective measures or clinician assessments could strengthen the validity of psychological assessments. Furthermore, the study identified predictors of return to work but did not delve deeply into the effectiveness of interventions for those identified as needing treatment for depression symptoms or pessimism. Future research could explore the impact of targeted interventions on facilitating early return to work, providing a more comprehensive understanding of effective strategies for this population. Lastly, the study primarily focused on the first year after trauma, leaving a gap in knowledge about long-term trajectories and factors influencing sustained work participation beyond this period. Addressing these research gaps would contribute to a more nuanced and comprehensive understanding of work outcomes following trauma.

In Jella et al’s. [ 12 ] retrospective cross-sectional study, the goal was to comprehend the prevalence and determinants associated with simultaneous mental illness and financial obstacles to mental health care following orthopaedic trauma. Conducted through an interview-based survey across a representative sample of 30,000 US households, the study included 2309 respondents who reported a fracture within the past 3 months, spanning from 2004 to 2017. The main outcome measurements focused on determining the prevalence and factors related to concurrent severe mental illness and financial barriers to mental health care, considering sociodemographic and injury characteristics.

Analysis revealed that 7.8% (95% CI 6.4–9.2%) of orthopaedic trauma survivors experienced severe mental illness, with 25.3% (95% CI 18.0–32.6%) and 40.9% (95% CI 31.5–50.2%) reporting financial barriers to counseling and pharmacotherapy, respectively. Factors associated with simultaneous severe mental illness and cost barriers included the age group of 45–64 years, income below 200% of the Federal Poverty Threshold, and unemployment at the time of injury [ 12 ]. These results suggest substantial financial obstacles to mental health services for approximately half of orthopaedic trauma survivors with severe mental illness, with younger, minority, and low socioeconomic status patients being disproportionately affected. The data underscore the existence of postdiagnosis disparities in mental health access, emphasizing the potential improvement through the direct provision and subsidization of integrated mental health support services, particularly for high-risk populations.

While Jella et al. [ 12 ] shed light on the significant issue of financial barriers to mental health services among orthopaedic trauma survivors with severe mental illness, there are notable gaps in the existing research that warrant further exploration. Specifically, there is a lack of study of the nuanced factors contributing to these disparities, considering the intricate interplay of sociodemographic variables, injury characteristics, and regional variations. Understanding the specific mechanisms through which age, ethnicity, and socioeconomic status impact access to mental health care post-orthopaedic trauma could inform targeted interventions.

Additionally, there is a need for longitudinal investigations to track the trajectory of mental health disparities over time, assessing how financial barriers evolve during the recovery process. Examining the long-term implications of these barriers on mental health outcomes, rehabilitation progress, and overall quality of life could provide valuable insights into the persistence and amplification of disparities beyond the immediate post-diagnosis period.

Furthermore, future research could explore the effectiveness of different interventions aimed at mitigating financial obstacles to mental health care. Intervention studies that evaluate the impact of integrated mental health support services, subsidies, or other policy-level initiatives on improving access for high-risk populations would contribute substantially to the evidence base. Understanding the mechanisms through which these interventions operate and their scalability across diverse healthcare settings could guide the development of targeted strategies to address existing disparities and promote equitable mental health care for orthopaedic trauma survivors.

Minimally invasive fracture repair methods, coupled with advancements in implant design, have proven successful, resulting in higher union rates and fewer complications compared to traditional open fracture repair methods [ 25 ]. However, open tibial fractures pose ongoing challenges despite recent progress in fracture care. Long-term assessments, such as the Lower Extremity Assessment Project (LEAP), reveal persistent issues with poor outcomes, as many patients struggle with disability even years after injury [ 25 ].

Outcomes research highlights widespread psychological distress following musculoskeletal trauma. Numerous studies demonstrate elevated rates of psychological distress among trauma patients, significantly influencing functional outcomes. Despite this correlation, there is a notable absence of studies evaluating clinicians’ ability to address psychological distress after musculoskeletal trauma, and psychological distress is seldom considered in orthopaedic outcome assessments. Addressing psychological distress, which significantly impacts trauma outcomes, remains a substantial yet often overlooked problem in orthopaedics that is need of attention and intervention.

In caring for individuals with orthopaedic trauma, it is imperative for healthcare professionals, including surgeons and the broader care team, to skillfully recognize symptoms indicative of depression, posttraumatic stress disorder (PTSD), and anxiety. Given the prevalence of psychiatric disorders in this patient population and the established correlation with adverse outcomes, it is paramount for institutions to integrate systematic screening processes into routine practices, ensuring the timely identification of these disorders. Orthopaedic surgeons, being integral to patient care, should be well-versed in available resources within their institution or community, facilitating appropriate referrals to specialists or therapists for comprehensive treatment. Early recognition and intervention for psychiatric symptoms have the potential to enhance patient recovery and significantly improve overall outcomes.

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Scott, S., Brameier, D.T., Tryggedsson, I. et al. Prevalence, resources, provider insights, and outcomes: a review of patient mental health in orthopaedic trauma. J Orthop Surg Res 19 , 538 (2024). https://doi.org/10.1186/s13018-024-04932-4

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How To Create High-Quality Content

Improve your SEO with high-quality content. Learn what defines it and how to effectively create and present it to your audience.

SEO success depends on providing high-quality content to your audiences. The big question is: What exactly does “high quality” mean?

Content has many meanings. In digital marketing, it simply means the information a website displays to users.

But don’t forget: In a different context with a different emphasis on the word (con tent as opposed to con tent), content is a synonym for happy and satisfied. The meaning is different, but the letters are the same.

If you want to understand content quality online, keep these two different definitions in mind.

Every webpage has content. “High-quality” content depends on contexts like:

• What the needs of your audience are.
• What users expect to find.
• How the content is presented and how easy it is to pull critical information out of it quickly.
• How appropriate the medium of the content is for users’ needs.

What Makes Content High Quality?

This is a complex question that we hope to answer in full during this article. But let’s start with a simple statement:

High-quality content is whatever the user needs at the time they’re looking for it.

This might not be helpful in a specific sense but note this somewhere because it’s a guiding light that has far-reaching implications for your website and audience strategy.

We use this definition because the quality of your content isn’t static. Google and other search engines know this and frequently update search engine results pages (SERPs) and algorithms to adjust for changing user priorities.

You need to bake this idea into your understanding of content and audiences. You can have the most beautifully written, best-formatted content, but if your target audience doesn’t need that information in that format, it’s not “high-quality” for SEO.

If you provide a story when the user is looking for a two-sentence answer, then you’re not serving their interests.

This is especially pertinent with the introduction of generative AI features into search platforms. This is a continuation of a “ zero click ” phenomenon for certain types of searches and why Google doesn’t send a user to a website for these searches.

Defining & Meeting Audience Needs

SEO professionals have many different ways of conceptualizing these ideas. One of the most common is “ the funnel ,” which categorizes content into broad categories based on its position in a marketing journey.

The funnel is usually categorized something like this:

• Top of the funnel : Informational intent and awareness-building content.
• Middle of the funnel : Consideration intent and product/service-focused content.
• Bottom of the funnel : Purchase intent and conversion content.

While it’s helpful to categorize types of content by their purpose in your marketing strategy, this can be an overly limiting view of user intent and encourages linear thinking when you conceptualize user journeys.

As Google gets more specific about intent , such broad categorization becomes less helpful in determining whether content meets users’ needs.

Build a list of verbs that describe the specific needs of your audience while they’re searching. Ideally, you should base this on audience research and data you have about them and their online activity.

Learn who they follow, what questions they ask, when a solution seems to satisfy them, what content they engage with, etc.

Then, create verb categories to apply to search terms during your keyword research. For example:

User Intends To Purchase

If the user is looking for something to buy, then high quality probably looks like a clean landing or product page that’s easy to navigate. Be sure to include plenty of detail so search engines can match your page to specific parameters the user might enter or have in their search history.

Product photos and videos, reviews and testimonials, and Schema markup can all help these pages serve a better experience and convert. Pay particular attention to technical performance and speed.

Remember that you’re highly likely to go up against ads on the SERPs for these queries, and driving traffic to landing pages can be difficult.

User Intends To Compare

This could take a couple of different forms. Users might come to you for reviews and comparisons on other things or to compare your benefits to those of another company.

For this content to be successful, you need to be dialed into what problems a user is trying to solve, what pain points they have, and how specific differences impact their outcomes.

This is the old “features vs. benefits” marketing argument, but the answer is “both.” Users could want to see all the features listed, but don’t forget to contextualize how those features solve specific problems.

User Intends To Discover

This intent could describe a user looking for industry news, data to support their research, or new influencers to follow.

Prioritize the experience they’re seeking and ensure that the discovery happens quickly.

This could look like adding text summaries or videos to the top of posts, tables of contents to assist with navigation, or page design elements that highlight the most critical information.

User Intends To Learn

If a user intends to learn about a topic, a long, well-organized post, video, or series of either may serve them best. This content should be in-depth, well-organized, and written by genuine topic experts. You may need to demonstrate the author’s qualifications to build trust with readers.

You must consider the existing knowledge level of your target audience. Advanced content will not satisfy the needs of inexperienced users, while basic content will bore advanced users.

Don’t try to satisfy both audiences in a single experience. It’s tempting to include basic questions in this type of content to target more SEO keywords, but think about whether you’re trading keywords for user experience.

For example, if you write a post about “how to use a straight razor” and your subheadings look like the ones below, you’re probably not serving the correct intent.

• What is a straight razor?
• Are straight razors dangerous?
• Should I use a straight razor?

The chances are high that someone landing on your page “how to use a straight razor” doesn’t need answers to these basic questions. In other words, you’re wasting their time.

User Intends To Achieve

A slightly different intent from learning. In this instance, a user has a specific goal for an action they want to perform. Like learning content, it should be written by subject matter experts.

If the person creating this content doesn’t have sufficient first-hand experience, they won’t effectively guide users and predict their real-world needs. This results in unsatisfying content and a failure point of many SEO content strategies.

In SEJ’s SEO Trends 2024 ebook , Mordy Oberstein , Head of SEO Brand at Wix, said:

“One trend I would get ahead of that aligns with Google’s focus on expertise and experience is what I’m coining “situational content.” Situational content attempts to predict the various outcomes of any advice or the like offered within the content to present the next logical steps. If, for example, a piece of content provides advice about how to get a baby to sleep through the night, it would then offer the next steps if that advice didn’t work. This is “situational” – if X doesn’t work, you might want to try Y. Situational content creates a compelling form of content I see more frequently. It does a few things for the reader: It addresses them and their needs directly. It’s more conversational than standard content (an emerging content trend itself). To predict various outcomes and situations, you have to actually know what you’re talking about. That latter point directly addresses E-E-A-T. You can only predict and address secondary situations with expertise and experience. Most of all, situational content indicates to the user that a real person, not a large language model (LLM), wrote it.”

The difference between “learn” and “achieve” intents can be difficult to see. Sometimes, you might need to satisfy both. Pay careful attention to these types of content.

User Intends To Check

Misunderstanding when a user just wants to “check” something can cause you to waste resources on content doomed not to perform, and another failure point of SEO strategies. If what a user needs can be solved in a few sentences, you’re in zero-click territory.

For example, ‘How to tie a bowtie’.

That is, Google will serve users an answer on the SERP, and they may not click a link at all. You may want to target these types of queries as part of longform content for other search intents using good content organization and Schema markup.

That way, you can give your authoritative and in-depth content opportunities to show up in rich results on SERPs, and users might click through if they see more information available or have follow-up questions.

You should consider these intents part of your SEO strategy, but think of them as awareness and branding tactics. AI features such as AI Overviews in Google seek to surface quick answers to queries. It will be much harder to acquire clicks on SERPs where features like this are activated.

If you struggle to understand why well-written content is losing traffic, you should assess whether you wrote hundreds of words to answer a query that only needed 30.

More intents exist, and to complicate matters further, they are not exclusive to each other in a single piece of content. Comparison and discovery intents, for example, often combine in listicles, product comparisons, and titles like “X alternatives to X.”

More reading about user intent:

• How People Search: Understanding User Intent
• Creating Content That Satisfies Search Intent & Meets Customer Needs
• Understanding Buyer Intent Keywords
• Google Patent: Rewriting Queries Based on Context to Meet Intent

Continue reading this article 👇

Content Quality Signifiers

While there’s no quantifiable answer to what good content means, there are many ways to evaluate it to ensure it contains key signs of quality.

Google’s content guidelines provide some questions you can ask yourself to objectively assess your content’s quality.

The SEO content mantra is E-E-A-T: Experience, Expertise, Authoritativeness, and Trustworthiness .

Google uses many signals to approximate these concepts and apply these signals to ranking algorithms. To be clear, E-E-A-T are not ranking factors themselves. But they are the concepts that ranking systems attempt to emulate via other signals.

These concepts apply to individual pages and to websites as a whole.

Experience : Are the people creating content directly knowledgeable about the subject matter, and do you demonstrate credible experience?

Expertise : Does your content demonstrate genuine expertise through depth, accuracy, and relevance?

Authoritativeness : Is your website an authoritative source about the topic?

Trust : Is your website trustworthy, considering the information or purposes at hand?

In its content guidelines, Google says this about E-E-A-T:

“Of these aspects, trust is most important. The others contribute to trust, but content doesn’t necessarily have to demonstrate all of them. For example, some content might be helpful based on the experience it demonstrates, while other content might be helpful because of the expertise it shares.” Understanding these concepts is critical for building a content strategy because publishing content with poor E-E-A-T signals could impact your website as a whole . Google’s language downplays this potential impact, but it’s critical to know that it’s possible. It’s tempting to assume that because a website has high “authority” in a general sense or in one particular area, anything it publishes is considered authoritative. This may not be true.

If you chase traffic by creating content outside your core areas of authority and expertise, that content may perform poorly and drag the rest of your site down.

More reading about E-E-A-T:

• Google E-E-A-T: What Is It & How To Demonstrate It For SEO
• Is E-E-A-T A Ranking Factor?
• Google’s E-E-A-T & The Myth Of The Perfect Ranking Signal
• E-E-A-T’s Google Ranking Influence Decoded

Creating Effective SEO Content

This article focuses on written content, but don’t neglect multimedia in your content strategy.

The thought process behind content should go a little bit like this:

Audience > Query (Keywords) > Intent > Brief / Outline > Create

You can also express it as a series of questions:

• Audience: Who is our audience?
• Query : What are they searching for?
• Intent : Why?
• Brief : How can we best assist them?
• Create : What does exceptional user experience look like?

Keyword Research For Content

Keyword research is a massive topic on its own, so here are some key pieces of advice and a few additional resources:

• Look at the SERPs for the keywords you target to understand what Google prioritizes, what your competitors are doing, what success looks like, and whether there are gaps you can fill.
• Cluster related keywords together and develop a content strategy that covers multiple branching areas of a topic deeply.
• High search volume often means high competition. Allocate your resources carefully between acquiring lower competition positions and fighting for a slice of competitive traffic.
• Building a robust catalog of content focused on long-tail keywords can help you acquire the authority to compete in more competitive SERPs for related topics.

More reading about keyword research:

• Keyword Research: An In-Depth Beginner’s Guide
• How to Do Keyword Research for SEO: The Ultimate Guide
• Keyword Mapping: A Beginner’s Guide

Briefing SEO Content

Once you have performed your research and identified the intents you must target, it’s time to plan the content.

SEO professionals may not have the required knowledge to create content that demonstrates experience and expertise – unless they’re writing about SEO.

They’re SEO specialists, so if your website is about finance or razor blades, someone else will need to provide the knowledge.

Briefing is critical because it allows the SEO team to communicate all that hard work and research to the person or team creating the content. A successful brief should inform the content creators:

• The target keyword strategy , with suggestions or a template for the title and subheadings.
• The purpose of the content for the user : What the user should learn or be able to accomplish.
• The purpose of the content for the business : Where it falls into the marketing strategy and relevant KPIs.
• Details such as length, style guide or voice notes, and key pieces of information to be included.

Creating SEO Content

Your research should guide the format of your writing.

Remember, intent impacts the usability of different types of content. Prioritize the information most likely to solve the user’s intent.

You can do this by providing summaries, tables of contents, videos, pictures, skip links, and, most importantly, headings.

Use The Title & Headings To Target Keywords & Organize Information

The title of a page is your primary keyword opportunity. It’s also the first thing users will see on a SERP, which impacts CTR. Match the title to your target query and think about effectively describing the content to entice a click. But don’t misrepresent your page for clicks.

Your primary responsibility in SEO content is to set expectations and then deliver on them. Don’t set if you can’t deliver.

HTML heading formats help users navigate the page by breaking up blocks of text and indicating where certain topics are covered. They’re critical to your on-page SEO, so use your keywords.

Expectations are as true for headings as for titles. Headings should be descriptive and useful. Prioritize setting an expectation for what the user will find on that part of the page and then delivering on that expectation.

More reading about headings:

• How To Use Header Tags: SEO Best Practices
• 14 Most Important Meta And HTML Tags You Need To Know For SEO
• Google Explains How to Use Headings for SEO
• 16 Free Title Generator Tools For Writing Better Headlines
• How To Write A Headline: 10 Tips For Getting It Right

Get To The Point

Whether content should be long or short is subjective to its purpose. All SEO content should be as short as possible while achieving its goals. “As short as possible” could mean 4,000 words.

If you need 4,000 words to achieve your goal, then use them. But don’t add any more than you need.

This is a call to avoid rambling, especially in introductions. Do you  really  need to cite the projected growth of an industry just to prove it’s worth talking about?

Not unless you’re writing a news story about that growth. Cut that sentence and the link to Statista from your introduction. (No shade, Statista, you rock.)

Features like skip links can also help with this. Give users the option to skim and skip directly to what they need.

Use Internal Links To Connect Your Pages Together & Provide Further Reading

Internal links are the bedrock of SEO content strategies. They are how you organize related pages and guide users around your website. They also spread the SEO value of your pages to the pages they’re connected to.

In the keyword research section, we suggested that you create clusters of keywords and topics to write about – this is why. You build authority by covering a topic in-depth and creating multiple pages exploring it and all its subtopics.

You should link between pages related to one another at contextually important points in the content. You can use this tactic to direct the SEO power of multiple pages to one important page for your strategy or your business.

Contextually relevant links that properly set expectations for what the user will find also contribute to a good site experience.

More reading about internal linking:

• Internal Linking is Super Critical For SEO
• Sentence-Level Semantic Internal Links For SEO
• Internal Link Structure Best Practices to Boost Your SEO
• How Should We Internally Link Hub & Spoke Content For SEO?

Use Personal Experiences And Unique Expertise To Stand Out

AI presents numerous challenges for SEOs. Anyone can quickly create content at scale using generative AI tools.

The tools can replicate competitors, synthesize content together from myriad sources, and enable breakneck publishing paces. This poses two core problems:

• How do you stand out with so much AI content out there?
• How do you build trust in audiences looking for legitimate experts?

For now, the best answer is to lean into the E-E-A-T principles that Google prioritizes.

• Tell human stories with your content that demonstrate your experience and expertise.
• Use Oberstein’s “situational content” principle, mentioned earlier in this article, to connect with your audience’s experiences and needs.
• Ensure that content is created by verifiable experts, especially if that content involves topics that can impact the audience’s well-being (YMYL.)

SEO Content Is Both A Strategy & An Individual Interaction

It’s easy to focus on what you need from users: what keyword you want to rank for, what you want users to click, and what actions you want them to take.

But all of that falls apart if you don’t honor the individual interaction between your website and a user who needs something.

Audience-first content is SEO content. Content is a core function of SEO because it’s the basis of how humans and algorithms understand your website.

More resources: 

• AI Agnostic Optimization: Content For Topical Authority And Citations
• Trending Content Output Compared In ChatGPT, Gemini, And Claude
• Content Marketing: The Ultimate Beginner’s Guide to What Works

Featured Image: Art_Photo /Shutterstock

In a world ruled by algorithms, SEJ brings timely, relevant information for SEOs, marketers, and entrepreneurs to optimize and grow ...

The ORS Journals: The Journal of Orthopaedic Research – Spine (JORS) 

Call for new editor-in-chief.

The Journal of Orthopaedic Research – Spine (JORS) was established in 2018 by the Orthopaedic Research Society (ORS) in order to offer a platform to focus on basic and translational orthopaedic research of the spine. The Journal is a leading peer reviewed, open access forum for the publication of premier spine studies focused on the biological basis of development, growth, aging and degeneration, biomechanical and novel imaging methods, mechano-biology, biomaterial applications, and pre-clinical and clinical studies based on novel preventative and regenerative approaches. The three founding co-Editors-in-Chief of JORS have recently announced their collective intent to depart from the Journal. For a full description of the role, including requirements, please visit the link below.

Applications for the role are being accepted from now until August 31, 2024.

The ORS produces two internationally renowned, peer reviewed musculoskeletal journals, the Journal of Orthopaedic Research (JOR) and the Journal of Orthopaedic Research – Spine (JORS) . These journals offer a comprehensive and multidisciplinary approach to orthopaedic research, ensuring that you stay informed, connected, and contribute to the advancement of this crucial field.

JOR and JORS are committed to publishing high-quality research that undergoes a rigorous peer-review process. Readers can trust the accuracy and reliability of the information presented in these journals.

The Journal of Orthopaedic Research – Spine (JORS)  

JORS is an open access journal that publishes research on topics such as: aging, degeneration, biologic therapies, biomaterials, tissue engineering, biomechanics, bioreactors, culture systems, development, and deformity.

Early View Current Issue All Issues Special Collections

See information on the Journal of Orthopaedic Research (JOR)  

Get Published

ORS members are exempt from submission fees. If any co-author is an ORS member, the submitting author can choose the Member article option, even if they are not a member themselves.

Reasons to Publish

• High standard peer review
• Reporting work dealing with a variety of subjects
• Quality and reputation, supported by ORS
• Rapid and transparent publication process
• Immediate open access in JORS

Please visit the Wiley Online Library to learn more about getting published in an Orthopaedic Research Society Journal. 

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'On the Shoulders of Giants': Documentary explores NYU Langone's orthopedic legacy

"On the Shoulders of Giants," a documentary that chronicles the history of NYU Langone orthopedics, wasn't originally supposed to be an hour-long feature.

The documentary's director, Peter Sanders, told Becker's that the film was commissioned to be a 30-minute movie. However he suggested turning the production into a feature-length film to executive producers, Kenneth Egol, MD, and Joseph Zuckerman, MD. The documentary would later become one of the four finalists for Best Documentaries at the 23rd Tribeca Festival .

Mr. Sanders became involved with the project after Dr. Egol, an orthopedic surgeon, suggested the project when the director was a patient.

"[Orthopedic surgeons] are unrecognized heroes," Mr. Sanders said. "Dr. Egol will say that you have not met him until you're in dire straits and then, when you do need him, he does the most unbelievable heroic things to make your body work again, to walk again… The pioneers have already paved the way for so many innovations in the last 165 years, and the future of orthopedics is built on that legacy. The future will take NYU Langone orthopedics to places that our imagination cannot even fathom."

Dr. Egol said he had the notion to document the orthopedic history for a few years, and the extra time from the COVID-19 pandemic helped kickstart things.

"We thought it'd be a good idea to start looking at all the luminary orthopedic surgeons in the history of the hospital and write a biography," Dr. Egol told Becker's . "So we spent a couple years putting together about 22 or 23 biographies that we published. In doing that and learning their stories, that's where we got the idea to put it all together and make a [documentary]." 

"On the Shoulders of Giants" is as much a history of orthopedics as it is about NYU Langone Orthopedic Hospital's growth. The documentary outlines the path from its association with Bellevue Medical College, the Hospital for Joint Diseases and what is now NYU Langone Orthopedic Hospital. 

The movie highlights orthopedic pioneers including Lewis Sayre, MD, the first orthopedic professor in North America, who worked at Bellevue Hospital Medical College, Marian Sloane, MD, the first female orthopedic surgeon in the U.S. to publish a peer-reviewed journal and J. Serge Parisien, MD, who helped develop modern arthroscopic techniques.

Another unique pillar of the documentary is music. Classical works are weaved throughout the film, including composers Wolfgang Amadeus Mozart, Johann Sebastian Bach and Antonín Dvořák. 

One of the prominent works is Dvořák's String Quartet No. 12 ("American Quartet"), which is included throughout the documentary. Its contemplative second movement opens the movie; the upbeat viola melody from the first movement introduces Joseph Milgram, MD, the first chair of orthopedics at The Hospital for Joint Diseases, and the jubilant third movement arises during a segment about orthopedic innovation and solutions.

Mr. Sanders' mother, musicologist Malena Kuss, helped select music for the documentary and she performed Beethoven's piano sonata Op. 2 No. 3 for the film, the director said. The choice to add the iconic Dvořák quartet came from Andrew Coffman, the documentary's editor. 

"It's a question of affinities," Mr. Sanders said, explaining the strategies used to select the music. "How do you make a movie? You have a beginning, a middle and an end. You divide each unit, matching emotionally the content of a segment and these contrasts, variations, and repetitions, carry an affinity with the context and drive the narrative forward. You'll recognize the Dvořák "American" string quartet, which is a perfect match for remembering the pioneers. Dvořák was a very good selection that has great affinities with the tone and the style of the film."

Looking ahead, Mr. Sanders is working on an audio and visual project to further explore NYU Langone's orthopedic surgeons and history. Those works will be available on the NYU Langone Orthopedic Hospital's website and onsite at the hospital by the end of the year. 

At the hospital, the next chapter for its orthopedic legacy lies especially in the physicians it trains. 

"The success of our training program, which is now 100 years old, started in 1923 really rests on the dedication of the faculty," Dr. Egol said. "Our primary missions are to take care of patients, but also to train the future orthopedic surgeons. Everybody here who's involved in our department loves teaching, scholarly activity and the pursuit of academic activities. We have the largest residency training program in the country."

With more than 100 trainees coming through NYU Langone Orthopedics each year, their collective reach extends beyond the region.

"Our impact on orthopedics is not only in the people we train, but geographically, is throughout the Tri-state area and expanding into other areas," Dr. Zuckerman said. "We've always said that the legacy of what we do is not necessarily in the patients we care for, although that's important … However, when you look at all the orthopedic surgeons that we graduate, who then go out and take care of hundreds of thousands of patients and do hundreds of operations each year, that is a tremendous cascading effect. We have a tremendous impact on orthopedic care in this country, and that's very important to us."

"On the Shoulders of Giants" is available on Apple TV, Amazon Prime and Google Play. It will be added to Kanopy, Vudú Fandango, inDemand, Hoopla, Microsoft, Direct TV and Dish Echostar on Oct. 4. In 2025, the documentary will be available on Tubi, and a Roku streaming deal is pending.

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