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Comparative Study
. 2025 Jan;33(1):308-318.
doi: 10.1002/ksa.12336. Epub 2024 Jun 29.

Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study

Margot B Aalders  1   2   3   4 , Jelle P van der List  1 , Lucien C M Keijser  1   2 , Joyce L Benner  1   5   6
Affiliations
Comparative Study

Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study

Margot B Aalders et al. Knee Surg Sports Traumatol Arthrosc. 2025 Jan.

Abstract

Purpose: The aim of this study was to investigate the influence of preoperative anxiety and depression on subjective function, pain and revision rates following total knee arthroplasty (TKA).

Methods: A prospective comparative study was conducted, including 349 patients undergoing TKA surgery between January 2019 and April 2021. Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire preoperatively, and a set of Patient-Reported Outcome Measures (PROMs) preoperatively and at 6, 12 and 24 months postoperatively. Patients were categorized into anxiety and depression groups based on HADS scores. PROMs included the Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS) and NRS-Pain. Differences in PROM scores between the anxiety/depression group and, respectively, nonanxiety/nondepression group were assessed, as well as differences in minimal clinical important difference (MCID) and attainment of Patient Acceptable Symptom State (PASS). Lastly, revision rates were compared.

Results: Anxiety and depression groups exhibited inferior subjective function preoperatively and postoperatively compared to nonanxiety and nondepression groups (all p < 0.05), experienced more pain preoperatively (p < 0.001) and also postoperatively for depression patients (all p < 0.05). Significantly fewer patients with anxiety and depression reached the PASS for KOOS-PS, OKS and NRS-Pain (all p < 0.05). There were no differences in the proportion of patients reaching the MCID for all PROMs (all p > 0.060), and revision rates did not differ between groups (both p > 0.96).

Conclusion: Preoperative anxiety and depression negatively influence subjective function and pain preoperatively and up to 2-year follow-up in patients undergoing TKA. Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain.

Level of evidence: Level II, prospective comparative study.

Keywords: Hospital Anxiety and Depression Scale; anxiety; depression; knee replacement; psychological factors; total knee arthroplasty.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of the study population: patient selection and lost to follow‐up, including the response rate and number of drop‐outs, that is, excluded patients during the inclusion period. LTFU, lost to follow‐up; PROM, Patient‐Reported Outcome Measure. Microsoft Word was used to create this figure.
Figure 2
Figure 2
Anxiety and nonanxiety patients: Course of the subjective function (a: Knee injury and Osteoarthritis Outcome Score‐Physical Function Shortform and b: Oxford Knee Score) and joint pain (c: Numeric Rating Scale‐pain), from preoperative to all follow‐up moments, for anxiety (in red) and nonanxiety (in green) patients. Corresponding Tables 2, 3, 4. SPSS was used to create this figure.
Figure 3
Figure 3
Depression and nondepression patients: Course of the subjective function (a: Knee injury and Osteoarthritis Outcome Score‐Physical Function Shortform and b: Oxford Knee Score) and joint pain (c: Numeric Rating Scale‐pain), from preoperative to all follow‐up moments, for depression (in red) and nondepression (in green) patients. Corresponding Tables 2, 3, 4. SPSS was used to create this figure.
See this image and copyright information in PMC

References

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