Depression As a Predictor of Postoperative Pain and Function After Total Knee Arthroplasty: Meta-Analysis of Prospective Comparative Studies Publisher Pubmed



Vosoughi F ; Taghva Nakhjiri M ; Ayati Firoozabadi A ; Gholami Chahkand M S ; Fatemi N S ; Metanat S ; Menbari Oskouie I
Source: Journal of Arthroplasty Published:2026

Abstract

Background Depression is common among patients undergoing total knee arthroplasty (TKA) and has been associated with worse patient-reported outcomes after surgery. However, it remains unclear whether preoperative depression limits postoperative improvement or primarily influences absolute postoperative pain and function levels. We asked the following questions: (1) Are postoperative pain and patient-reported functional outcomes different in patients who had preoperative depression compared with those who did not after primary TKA? (2) Does preoperative depression influence the magnitude of postoperative improvement? and (3) Is preoperative depression associated with postoperative satisfaction? Methods We performed a systematic review and meta-analysis of prospective comparative studies evaluating outcomes after primary TKA in patients who had and did not have preoperative depression. A total of four databases were searched from inception to September 2025. There were 10 prospective studies involving 2,682 patients (572 who had depression) that were included. Pain, patient-reported functional outcomes (Western Ontario and McMaster Universities Osteoarthritis Index and Knee Society Score), and satisfaction were analyzed using random effects models. Risk of bias was assessed using Risk of Bias in Non-Randomized Studies (ROBINS-I). Because of clinical and methodological heterogeneity, results were interpreted cautiously. Results Patients who had depression reported worse preoperative pain and, postoperatively, higher residual pain and lower absolute patient-reported functional scores compared with nondepressed patients. However, the magnitude of postoperative improvement in pain and function was generally similar between groups. Preoperative depression was not reliably associated with postoperative dissatisfaction. Heterogeneity across pooled analyses was substantial. Conclusions Both depressed and nondepressed patients achieved comparable improvements in pain and function following TKA, indicating that postoperative gains (delta change) are similar between groups. Although preoperative depression is associated with worse baseline status and lower absolute postoperative patient-reported outcome measure scores, it does not appear to meaningfully limit the degree of improvement after surgery. These findings suggest that depression modifies symptom perception rather than surgical efficacy. Depression should not be considered a contraindication to TKA, but preoperative identification and counseling may help optimize patient expectations and postoperative care. Level of Evidence Level II, systematic review. © 2026 Elsevier Inc.