Sleep quality and its association with recovery in patients undergoing total knee arthroplasty: A systematic review: Sleep and total knee arthroplasty

Victor M. Vasquez Jr.; Micah Ngatuvai; Nehaa Sohail; Joshua Hansen; Joshua Rainey; Richard Purcell

doi:10.28982/josam.8219

Authors

Victor M. Vasquez Jr. Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, USA https://orcid.org/0009-0003-7790-1296
Micah Ngatuvai Department of Orthopedic Surgery, Texas Tech University Health Sciences Center El Paso, USA https://orcid.org/0000-0002-1433-4082
Nehaa Sohail Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, USA https://orcid.org/0009-0004-3097-9931
Joshua Hansen Department of Orthopedic Surgery, Texas Tech University Health Sciences Center El Paso, USA https://orcid.org/0000-0001-9657-8736
Joshua Rainey Department of Orthopedic Surgery, University of Utah, USA https://orcid.org/0000-0002-3362-2071
Richard Purcell Department of Orthopedic Surgery, Texas Tech University Health Sciences Center El Paso, USA https://orcid.org/0000-0002-5056-634X

DOI:

https://doi.org/10.28982/josam.8219

Keywords:

Total knee arthroplasty, sleep quality, recovery, Pittsburgh Sleep Quality Index, actigraphy

Abstract

Background/Aim: Sleep disturbances are a prevalent but often overlooked issue among patients undergoing total knee arthroplasty (TKA). These disruptions significantly contribute to increased pain, delayed functional recovery, and reduced quality of life. This systematic review examines the association between sleep quality and postoperative recovery outcomes after TKA.

Methods: The review utilized five databases: PubMed, Embase, Ovid/MEDLINE, CINAHL, and Scopus. We identified studies that evaluated sleep quality and recovery outcomes in adult TKA patients. Eligible studies used validated tools such as the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and actigraphy to examine recovery metrics, including pain, mobility, and overall recovery trajectories. A narrative synthesis was conducted to identify patterns and variations across the included studies.

Results: Seven studies, involving a total of 902 patients, were included in this review. Poor sleep quality is consistently correlated with adverse recovery outcomes, such as higher pain levels, slower functional recovery, and diminished quality of life. Quantitative data underscored the association between elevated PSQI scores and delayed recovery metrics. Patients with higher PSQI scores reported elevated pain levels (VAS: 3.8 vs. 1.6) and poorer functional outcomes, as indicated by significantly higher WOMAC-Physical Function scores several weeks after TKA compared to groups with less prominent insomnia (P<0.05).

Conclusion: Interventions targeting sleep disturbances, such as behavioral therapies, showed promising benefits. However, methodological variability limited the generalizability of findings. This review emphasizes the critical importance of sleep quality as a modifiable factor in optimizing recovery after TKA. Integrating sleep assessments and targeted interventions, such as cognitive-behavioral therapy for insomnia (CBT-I), into perioperative care can significantly enhance recovery trajectories and patient outcomes. Future research should prioritize standardizing methodologies and investigating the effectiveness of sleep-focused strategies across diverse patient populations.

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References

Nguyen USDT, Ayers DC, Li W, Harrold LR, Franklin PD. Preoperative Pain and Function: Profiles of Patients Selected for Total Knee Arthroplasty. J Arthroplasty. 2016 Nov;31(11):2402-7.e2.

NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003 Dec 8;20(1):1–34.

Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gómez-Barrena E, De Fátima De Pina M, Manno V, Torre M, Walter WL, De Steiger R, Geesink RGT, Peltola M, Röder C. International survey of primary and revision total knee replacement. Int Orthop. 2011 Dec;35(12):1783–9.

Klug A, Gramlich Y, Rudert M, Drees P, Hoffmann R, Weißenberger M, Kutzner KP. The projected volume of primary and revision total knee arthroplasty will place an immense burden on future health care systems over the next 30 years. Knee Surg Sports Traumatol Arthrosc. 2021 Oct;29(10):3287–98.

Finlayson K, Miaskowski C, Alexander K, Liu WH, Aouizerat B, Parker C, Maresco-Pennisi D, Edwards H. Distinct Wound Healing and Quality-of-Life Outcomes in Subgroups of Patients With Venous Leg Ulcers With Different Symptom Cluster Experiences. J Pain Symptom Manage. 2017 May;53(5):871–9.

Raymond I, Ancoliisrael S, Choiniere M. Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries. Sleep Med. 2004 Nov;5(6):551–9.

Long G, Suqin S, Hu Z, Yan Z, Huixin Y, Tianwang L, Yang Y, Zhenhu W. Analysis of patients’ sleep disorder after total knee arthroplasty-A retrospective study. J Orthop Sci. 2019 Jan;24(1):116–20.

Van Meirhaeghe JP, Salmon LJ, O’Sullivan MD, Gooden BR, Lyons MC, Pinczewski LA, Roe JP. Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients. J Arthroplasty. 2021 Feb;36(2):442–8.

Chen PY, Jan YW, Yang CM. Are the Insomnia Severity Index and Pittsburgh Sleep Quality Index valid outcome measures for Cognitive Behavioral Therapy for Insomnia? Inquiry from the perspective of response shifts and longitudinal measurement invariance in their Chinese versions. Sleep Med. 2017 Jul;35:35–40.

Parada Marcilla M. Importance of sleep quality in chronic pain. Ann Phys Rehabil Med. 2018 Jul;61:e117.

Sheffler JL, Saliga H, Pickett S. The Role of Physical Activity on the Relationships Between Pain, Anxiety, and Sleep Quality in Older Age. J Gerontol A Biol Sci Med Sci. 2023 Oct 9;78(10):1881–6.

Nithagon P, Rampam S, Thomas TL, Goh GS. How Do We Improve Sleep Quality After Total Joint Arthroplasty? A Systematic Review of Randomized Controlled Trials. J Am Acad Orthop Surg. 2024 Sep 10;

Sun JN, Chen W, Zhang Y, Zhang Y, Feng S, Chen XY. Does cognitive behavioral education reduce pain and improve joint function in patients after total knee arthroplasty? A randomized controlled trial. Int Orthop. 2020 Oct;44(10):2027–35.

Gibian JT, Bartosiak KA, Lucey BP, Riegler V, King J, Barrack RL. Sleep Disturbances Following Total Knee Arthroplasty. J Arthroplasty. 2023 Jun;38(6):S120–4.

Hamilton KR, Hughes AJ, Campbell CM, Owens MA, Pester BD, Meints SM, Taylor JL, Edwards RR, Haythornthwaite JA, Smith MT. Perioperative insomnia trajectories and functional outcomes after total knee arthroplasty. Pain. 2023 Dec 1;164(12):2769–79.

Mukartihal RK, Angadi DS, Mangukiya HJ, Singh NK, Varad S, Ramesh PA, Patil SS. Temporal changes in sleep quality and knee function following primary total knee arthroplasty: a prospective study. Int Orthop. 2022 Feb;46(2):223–30.

Owens MA, Mun CJ, Hamilton KR, Hughes A, Campbell CM, Edwards RR, Smith MT. Presurgical sleep and pain behaviors predict insomnia symptoms and pain after total knee arthroplasty: a 12-month longitudinal, observational study. Pain Med. 2023 Nov 2;24(11):1224–33.

Hamai S, Harada S, Tsushima H, Kozuma R, Yamate S, Kawahara S, Akasaki Y, Harada T, Kokubu Y, Konishi T, Nakashima Y. Interaction between functional capability and sleep quality at midterm after total knee arthroplasty: a Japanese retrospective cohort study. Sci Rep. 2023 Oct 26;13(1):18373.

Herrero-Sánchez MD, García-Iñigo MDC, Nuño-Beato-Redondo BS, Fernández-de-las-Peñas C, Alburquerque-Sendín F. Association between ongoing pain intensity, health-related quality of life, disability and quality of sleep in elderly people with total knee arthroplasty. Ciênc Saúde Coletiva. 2014 Jun;19(6):1881–8.

Hughes AJ, Richards JM, Campbell CM, Haythornthwaite JA, Edwards RR, Smith MT. 0910 Sleep-pain Behaviors Predict Insomnia, Pain, and Physical Function over One Year Following Total Knee Arthroplasty in Individuals with Knee Osteoarthritis. Sleep. 2018 Apr 27;41(suppl_1):A338–A338.

Nuñez M, Nuñez E, Segur J, Lozano L, Montañana J, Segura V, Marti M, Garcia-Cardo A, Sastre S, Alemany X. SAT0703 Influence of physical activity and sleep on functional capacity and pain in patients with knee osteoarthritis. Ann Rheum Dis. 2017 Jun;76:1041.

Kourbanova K, Alexandre C, Latremoliere A. Effect of sleep loss on pain-New conceptual and mechanistic avenues. Front Neurosci. 2022;16:1009902.

Mun CJ, Finan P, Weaver K, Hunt C, Owens M, Lerman S, Tennen H, Haythornthwaite J, Smith M. The intra-day link between sleep disturbance and pain severity among individuals with temporomandibular joint disorder: Pain expectancy as a potential mechanism. J Pain. 2021 May;22(5):611.

Giordano R, Capriotti C, Gerra MC, Kappel A, Østgaard SE, Dallabona C, Arendt‐Nielsen L, Petersen KK. A potential link between inflammatory profiles, clinical pain, pain catastrophizing and LONG‐TERM outcomes after total knee arthroplasty surgery. Eur J Pain. 2024 Aug;28(7):1202–12.

Giordano R, Ghafouri B, Arendt-Nielsen L, Petersen KKS. Inflammatory biomarkers in patients with painful knee osteoarthritis: exploring the potential link to chronic postoperative pain after total knee arthroplasty—a secondary analysis. Pain [Internet]. 2023 Sep 6 [cited 2025 Feb 15]; Available from: https://journals.lww.com/10.1097/j.pain.0000000000003042.