The John Insall award: Pain and depression influence outcome 5 years after knee replacement surgery

We previously reported preoperative depression, anxiety, and pain were associated with greater pain, more utilization of healthcare resources, and worse outcome 1 year after total knee arthroplasty. We asked whether these outcomes persisted over time and whether patients with unexplained heightened pain early after surgery were ultimately satisfied. We prospectively followed and evaluated 83 patients (109 TKAs) 5 years postoperative. The mean age was 66 years; 55% were women. Preoperative pain and depression predicted lower Knee Society score mostly related to lower function subscores. Although anxiety was associated with greater pain, worse function, and more use of resources in the first year after surgery, anxiety did not affect ultimate outcome. Most patients required a full year to recover from surgery but with negligible improvements in most parameters afterward. However, patients with heightened, unexplained pain at 1 year had progressive improvement in pain over several years. By 5 years, nearly all of these patients were satisfied. Therefore, assuming good range of motion and well-aligned implants, most patients with pain 1 year after surgery can be reassured pain ultimately improves. Depression drives long-term outcomes; the Knee Society score is influenced by psychologic variables and does not solely reflect issues related to the knee. Expansion of this tool to include measures sensitive to psychologic and other health factors should be considered. Level of Evidence: Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.