Abstract
Background: Depression has been identified as an important determinant of outcomes in hip and knee arthroplasty, but its impact on total ankle arthroplasty (TAA) remains unclear. Given the growing use of TAA as a treatment for end-stage ankle arthritis, understanding psychosocial risk factors is critical for optimizing surgical outcomes. This study aims to assess the effect of preoperative depression on clinical and functional outcomes following total ankle arthroplasty. Methods: A systematic review was conducted in accordance with PRISMA guidelines and prospectively registered with the Open Science Framework. PubMed, Cochrane Library, and CINAHL were searched through August 2025 for studies reporting outcomes of TAA stratified by depression status. Eligible designs included randomized trials, cohort studies and case series. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Given heterogeneity in study designs, depression definitions, and outcome measures, findings were synthesized narratively and summarized using a revised effect-direction plot. Results: Six unique studies involving approximately 9000 patients met inclusion criteria. Five studies were rated as good quality on the Newcastle-Ottawa Scale, while one study was judged to be of moderate quality. Four studies assessing pain outcomes consistently demonstrated worse postoperative pain or less improvement in patients with depression. Three of five studies assessing functional or disability outcomes reported reduced improvement, while two studies found no independent association. Two studies evaluating complications showed higher risks of adverse events, including prolonged hospital stay, non-home discharge, osteophytosis, and implant subsidence, among depressed patients. Revised effect-direction synthesis confirmed a consistent trend toward poorer outcomes across pain, function, and complication domains. Conclusions: Depression is associated with worse pain and higher complication rates following TAA, while its influence on functional recovery was not demonstrated uniformly. These findings support the importance of routine preoperative screening and targeted management of depression. Further prospective, multicenter studies and interventional trials are needed to clarify causality and optimize perioperative care.