Joint function has recovered, but the pain remains. A look at a study co-authored by our director
Record source: PubMed (U.S. National Library of Medicine), PMID 37086907. This study was conducted at other institutions and does not represent treatment outcomes at Ginza YR Clinic.
Patients with higher preoperative depression scores showed no significant difference in objective functional outcomes after total ankle arthroplasty.
However, on the patient-reported pain measure at one year after surgery, the higher-scoring group fared worse. What clinicians observed and what patients themselves felt did not align.
Note: This was an observational study of 20 patients. It demonstrates an association, not a causal relationship.
Recovery after total ankle arthroplasty varies from patient to patient. Some people regain good joint movement yet still live with pain. Why does that happen?
A study published in 2023 in The Journal of Foot & Ankle Surgery examined the relationship between preoperative depressive tendencies and clinical outcomes after transfibular total ankle arthroplasty.
Dr. Junya Higuchi, director of Ginza YR Clinic, took part in this research as a co-author while working in the Department of Orthopaedic Surgery at Teikyo University Mizonokuchi Hospital.
Key points
Study overview
| Title | Association of Preoperative Depression Score With Outcomes of Transfibular Total Ankle Arthroplasty |
|---|---|
| Journal | The Journal of Foot & Ankle Surgery (2023; 62(5):807-811) |
| Design | Observational study |
| Institutions | Teikyo University Mizonokuchi Hospital and others (not Ginza YR Clinic) |
| Participants | 20 patients who underwent transfibular total ankle arthroplasty |
| Mean age | 75 years |
| Diagnoses | Osteoarthritis 18 / rheumatoid arthritis 2 |
| Time points | Preoperatively, 6 months, and 1 year after surgery |
| Measures | JSSF scale, SAFE-Q, HADS, Timed Up & Go test |
| DOI | 10.1053/j.jfas.2023.04.004 |
Transfibular total ankle arthroplasty: Total ankle arthroplasty replaces a severely damaged ankle joint with an artificial one, with the aim of relieving pain and improving movement. This study looked at the transfibular approach, in which the surgeon reaches the joint from the fibular side.
Observational study: A study that analyses data from routine clinical care rather than assigning patients to treatments. This design can reveal associations between factors, but cannot establish that one caused the other.
How the study measured recovery
Four instruments were used. Some are scored by clinicians, others are completed by patients themselves — and that distinction is central to understanding the results.
| Measure | Scored by | What it assesses |
|---|---|---|
| JSSF scale | Clinician | Pain, function, and joint alignment |
| Timed Up & Go | Clinician | Time to stand, walk a set distance, and sit again |
| SAFE-Q | Patient | Pain, daily activities, social participation, general health |
| HADS | Patient | Anxiety and depressive tendencies |
SAFE-Q (Self-Administered Foot Evaluation Questionnaire): Each subscale is scored from 0 to 100, with higher scores indicating a better state. The instrument was designed to capture what patients themselves experience and how it affects their daily lives.
HADS (Hospital Anxiety and Depression Scale): A questionnaire that identifies anxiety and depressive tendencies. This study divided patients into two groups using the median preoperative HADS depression score. A “higher score” does not mean a patient has been diagnosed with depression.
Finding 1: No difference in objective function
Patients were divided into two groups based on the median preoperative HADS depression score.
On the JSSF scale and the Timed Up & Go test, no significant differences were observed between the groups, either before or after surgery.
Within the scope of this study, a higher preoperative depression score did not necessarily mean poorer objective joint function or mobility afterwards.
Finding 2: A difference in the pain patients reported
This is the heart of the study, and the part that calls for the most careful reading. Here are the figures at one year after surgery.
| SAFE-Q subscale | Higher depression score | Lower depression score |
|---|---|---|
| Pain subscale (median) | 59 | 90 |
| Other subscales | No significant differences between groups | |
Higher SAFE-Q scores indicate a better state. A median of 59 therefore means the higher depression score group reported a comparatively worse pain-related state.
In other words, joint function as clinicians observe it may recover while the pain patients feel does not improve in step. Objective function and subjective experience do not always match.
“Subjective pain” here does not mean the pain is absent or imagined. SAFE-Q was designed precisely to record what patients actually experience and how that shapes their daily lives.
Why this does not mean depression causes surgery to fail
There are four reasons.
What this study tells us
First, there is more than one way to measure treatment success. Looking only at imaging and range of motion can miss the pain patients actually feel and how it affects their lives.
Second, similar objective function can still mean different experiences. When deciding on treatment and assessing recovery, it helps to consider joint structure and the extent of damage, the character and duration of the pain, walking and daily activity, what the patient hopes the treatment will achieve, sleep and stress, and other conditions and circumstances in their life.
Third, this study shows an association and nothing more. With 20 patients and an observational design, it cannot predict any individual patient’s outcome from a preoperative score.
The measure of successful treatment is not only what the numbers show, but whether a person can return to the things they wanted to do.
This article is provided for general medical information and does not guarantee any particular treatment outcome. Symptoms and recovery vary between individuals. Please consult a physician for advice about your own situation.
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About this article
Written by
Ginza YR Clinic editorial team
Dr. Junya Higuchi, director of Ginza YR Clinic (PhD in Medicine, University of Tokyo; board-certified orthopaedic surgeon, Japanese Orthopaedic Association; member, Japanese Society for Surgery of the Foot), is a co-author of the paper discussed here. At the time of the research he was based in the Department of Orthopaedic Surgery, Teikyo University Mizonokuchi Hospital.
Medical information notice
This article is provided for general medical information and does not guarantee diagnosis, efficacy, or safety. The study described was an observational study conducted at other institutions and does not represent treatment outcomes at Ginza YR Clinic. Its results are statistical findings at the group level and cannot be used to predict outcomes for an individual patient.
This article is not intended to diagnose depression. If you are experiencing persistent low mood, sleep difficulties, or similar concerns, please consult an appropriate healthcare provider.
References
- Yasui T, Higuchi J, Kasai T, Yamada A, Kobata T, Hasebe K, Hara M. Association of Preoperative Depression Score With Outcomes of Transfibular Total Ankle Arthroplasty. J Foot Ankle Surg. 2023;62(5):807-811. https://doi.org/10.1053/j.jfas.2023.04.004
- Japanese Society for Surgery of the Foot. SAFE-Q (Self-Administered Foot Evaluation Questionnaire). https://www.jssf.jp/english/safeq.html
Last updated: September 9, 2026