Do symptoms of anxiety and/or depression and pain intensity before primary Total knee arthroplasty influence reason for revision? Results of an observational study from the Dutch arthroplasty register in 56,233 patients

Juliette C. Sorel*, Jacobien H. F. Oosterhoff, Birit F. P. Broekman, Ruurd L. Jaarsma, Job N. Doornberg, Frank F. A. IJpma, Paul C. Jutte, Anneke Spekenbrink-Spooren, Maaike G. J. Gademan, Rudolf W. Poolman

*Corresponding author for this work

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Objective: Anxiety, depression and greater pain intensity before total knee arthroplasty (TKA) may increase the probability of revision surgery for remaining symptoms even without clear pathology or technical issues. We aimed to assess whether preoperative anxiety/depression and pain intensity are associated with revision TKA for less clear indications. Methods: Less clear indications for revision were defined after a Delphi process in which consensus was reached among 59 orthopaedic knee experts. We performed a cox regression analyses on primary TKA patients registered in the Dutch Arthroplasty Registry (LROI) who completed the EuroQol 5D 3 L (EQ5D-3 L) anxiety/depression score to examine associations between preoperative anxiety/depression and pain (Numeric Rating Scale (NRS)) with TKA revision for less clear reasons. These analyses were adjusted for age, BMI, sex, smoking, ASA score, EQ5D-3 L thermometer and OKS score. Results: In total, 25.9% patients of the 56,233 included patients reported moderate or severe symptoms of anxiety/depression on the EQ5D-3 L anxiety/depression score. Of those, 615 revisions (45.5%) were performed for less clear reasons for revision (patellar pain, malalignment, instability, progression of osteoarthritis or arthrofibrosis). Not EQ5D-3 L anxiety/depression score, but higher NRS pain at rest and EQ5D-3 L pain score were associated with revision for less clear reason (HR: 1.058, 95% CI 1.019-1.099 & HR: 1.241, 95% CI 1.044-1.476, respectively). Conclusion: Our findings suggest that pain intensity is a risk factor for TKA revision for a less clear reason. The finding that preoperative pain intensity was associated with reason for revision confirms a likely influence of subjective, personal factors on offer and acceptance of TKA revision. The association between anxiety/depression and reason for revision after TKA may also be found when including more specific outcome measures to assess anxiety/depression and we therefore hope to encourage further research on this topic with our study, ideally in a prospective setting. Study design: Longitudinal Cohort Study Level III, Delphi Consensus

Original languageEnglish
Pages (from-to)42-49
Number of pages8
JournalGeneral Hospital Psychiatry
Publication statusPublished - Sep-2022


  • Arthroplasty
  • Delphi method
  • Implants
  • Knee
  • Primary knee arthroplasty
  • Revision surgery
  • RISK

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