Does preoperative anxiety and depression predict satisfaction after total knee replacement?

doi:10.1016/j.knee.2011.07.008

The Knee

Volume 19, Issue 5, October 2012, Pages 522-524

https://doi.org/10.1016/j.knee.2011.07.008 Get rights and content

Abstract

Background and purpose

Approximately one fifth of patients are not satisfied with the outcome of total knee arthroplasty (TKA). Preoperative variables associated with poorer outcomes are severity and chronicity of pain, psychological disease, poor coping strategies and pain catastrophisation. Psychological disease may be expressed as anxiety and depression. It is unclear whether anxiety and depression before TKA are constitutional or result from knee pain. The aim of this study was to explore the association of anxiety and depression with knee pain and function using specific outcome measures.

Methods

Forty consecutive patients undergoing TKA completed Hospital Anxiety and Depression Scale (HAD) and Oxford Knee Scores (OKS) preoperatively and at 3 and 6 months postoperatively.

Results

The HAD and OKS significantly improved post-operatively (p < 0.001). There was a greater change between the preoperative and postoperative scores in the OKS than the HAD. The severity of preoperative anxiety and depression was associated with higher levels of knee disability (coefficient − 0.409, p = 0.009). Postoperatively reduction in anxiety and depression was associated with improvement in knee disability after 3 (coefficient − 0.459, p = 0.003) and 6 months (coefficient − 0.428, p = 0.006).

Interpretation

The difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether they are the cause or effect of pain in the knee. As anxiety and depression improve with knee pain and function, this study suggests that knee pain contributes to the psychological symptoms and that a successful TKA offers an excellent chance of improving both.

Introduction

Some 18% of patients are not satisfied with the outcome of total knee arthroplasty (TKA) [1], [2], [3], [4], [5], [6]. Of those not satisfied, 9% are frankly dissatisfied and a further 9% are uncertain about the benefit of the procedure. If the preoperative variables associated with disappointing results could be identified before surgery, it might be possible to address them and target TKA more specifically.

The preoperative variables associated with poorer outcome after TKA are severity and chronicity of pain [7], [8], [9], psychological disease [6], [9], [10], [11], [12], [13] and poor coping strategies [8], [14], [15]. The psychological disease has generally been elicited for the Mental Component Score of Short Form 36 or 12 general health questionnaires which measure a combination of anxiety, depression and poor social support. Brander [9], using the Beck Depression Index, suggested that untreated depression was an independent risk for poor outcome after TKA. However, when other psychological outcome measures are used, the association between premorbid disease and poor outcome after TKA is less clear [11], [13], [16], [17].

Accordingly, it is not clear whether psychological distress before TKA is constitutional or results from knee pain. If it is constitutional, it might be possible to treat the symptoms, prepare patients better for surgery and reduce the proportion not satisfied with their TKA. With constitutional anxiety and depression, one would expect deterioration with the painful stimulus of TKA. If the anxiety and depression resulted from the pain and restricted function caused by osteoarthritis of the knee, one would expect improvement of both psychological and knee function after TKA.

The aim of this study was to explore the association of anxiety and depression with knee pain and function before and 3 and 6 months after TKA using well validated, specific outcome measures of anxiety and depression [18] and knee function.

Section snippets

Patients and methods

Forty consecutive patients undergoing tricompartmental TKA were enrolled. The procedures were carried personally or under the supervision of the senior author. The prosthesis used was the Triathlon (Stryker, Mahwah, New Jersey) implanted through the subvastus approach under general and spinal anaesthesia. Anxiety and depression were measured with the Hospital Anxiety and Depression (HAD) scale [18]. The HAD is a 14 item questionnaire which reliably detects depression and anxiety in a hospital

Ethics approval

Approval for the study was obtained from the Local Research Ethics Committee as a service evaluation as patients routinely completed the OKS and HAD. Verbal consent was obtained from all patients.

Statistical analysis

Data distribution was tested using Kolmogorov–Smirnov test. The distribution of data was normal. Where indicated Pearson correlation was used to evaluate the relationship between different variables. In order to compare the responsiveness of the two different scoring systems, effect size was used. The effect size was measured by dividing the change score (post-operative minus pre-operative score) by base line scores standard deviation [20]. SPSS (Version 13, SPSS Inc., Chicago IL) was used for

Results (Table 1)

The mean age of patients was 72 (range 52–88). Sixty percent (24/40) were female.

Preoperatively, the HAD scores were borderline in 11 of the 40 patients' and abnormal in four. After 6-month follow up, this fell to two borderline and one abnormal indicating significant clinical improvement (p = 0.001). Overall, the HAD significantly improved post-operatively. The mean HAD was 11.9 preoperatively, 5.6 after 3 months (p < 0.001) and 5.4 after 6 months (p < 0.001). The correlation coefficient was good at

Discussion

The difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether the psychological symptoms are the cause or effect of pain in the knee. The HAD is probably the most appropriate instrument for measuring anxiety and depression as it was designed to address these symptoms when they coexisted with physical disease.

This study suggests that preoperative knee pain contributes significantly to anxiety and depression but is not the sole contributor as

Conflict of interest statement

None of the authors have any financial or personal relationships with other people or organisations that could inappropriately influence (bias) their work.

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There are more references available in the full text version of this article.

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Citation Excerpt :
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Fifty patients undergoing RSA for rotator cuff insufficiency were prospectively included. Evaluation using the visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value, Hospital Anxiety and Depression Scale (HADS), and Abbreviated scale of World Health Organization Quality of Life (WHOQOL-BREF) was performed before surgery and at 1.5, 3, 6, and 12 months after surgery.
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Does preoperative anxiety and depression predict satisfaction after total knee replacement?

Abstract

Background and purpose

Methods

Results

Interpretation

Introduction

Section snippets

Patients and methods

Ethics approval

Statistical analysis

Results (Table 1)

Discussion

Conflict of interest statement

J Arthroplasty

Pain

Gen Hosp Psychiatry

The role of pain and function in determining patient satisfaction after total knee replacement

JBJS (Br)

Patient satisfaction after knee arthroplasty

Acta Orthop Scand

Patient expectations affect satisfaction with total knee arthroplasty

Clin Orthop Relat Res

Predicting patient dissatisfaction following joint replacement surgery

J Rheumatol

Predicting dissatisfaction following total knee replacement. A prospective study of 1217 patients

JBJS(Br)

Prospective relation between catastrophizing and residual pain after knee arthroplasty: two-year follow-up

Pain Res Manage

Pain and depression influence outcome 5 years after knee replacement surgery

Clin Orthop Relat Res