Perioperative Anxiety in Total Knee Arthroplasty: Clinical Consequences, Potential Mechanisms, and Management—A Narrative Review

Total knee arthroplasty (TKA) treats end-stage knee osteoarthritis, yet some patients report persistent pain, incomplete recovery, or dissatisfaction. Perioperative anxiety is a potentially modifiable factor associated with poorer outcomes. This narrative review examines its clinical consequences, mechanisms, and management in TKA. PubMed, Embase, Web of Science, and the China National Knowledge Infrastructure were searched without date or language restrictions through 25 September 2026. Evidence was stratified by anxiety-related selection at enrollment: studies of anxiety-selected patients provided direct evidence, whereas studies without such selection provided indirect evidence, regardless of whether anxiety was a primary, secondary, or exploratory outcome. Sixty studies underwent formal risk-of-bias appraisal. Higher anxiety was associated with greater postoperative pain and analgesic requirements and poorer patient-reported recovery and satisfaction, whereas findings for persistent pain and long-term function were less consistent. Proposed pathways include catastrophizing, kinesiophobia, reduced self-efficacy, pain sensitization, and stress-related biological processes. Pharmacological, psychoeducational, cognitive behavioral, digital, and adjunctive interventions may reduce anxiety, but direct evidence remains limited, and improvements do not consistently translate into less pain or opioid use, better function, or higher satisfaction. Anxiety may be considered in preoperative risk assessment, while standardized assessment and higher-quality trials remain needed.