Anesthetic Techniques and Patients -Related Determinant of Perioperative Outcomes in Orthopedics Surgery: A Cross-Sectional Analytical Study
Anesthesia in orthopedic surgery
Abstract
Background: Perioperative outcomes in orthopaedic surgery are influenced by multiple patient, surgical, and anaesthetic factors. This study aimed to identify predictors of preoperative anxiety, postoperative pain, side effects, analgesia needs, and mobilisation time.
Methods: A cross‑sectional study of 161 orthopaedic surgical patients. Associations were examined using chi‑square tests for sex, age, education, operation type, anaesthesia type, reason for anaesthesia selection, operation duration, and preoperative explanation.
Results: Preoperative anxiety (72.7%) was associated with anaesthesia type (p=0.046) and reason for selection (p=0.012). Postoperative pain (79.5%) and pain intensity were significantly associated with age, education, anaesthesia type, operation duration, and sex (pain intensity only). Regional and spinal anaesthesia produced the lowest pain rates, mildest pain, fewest side effects (8–11% vs. 84% for general), and lowest analgesia needs (33–56% vs. 79% for general). Younger age predicted more pain and delayed mobilisation; longer operation duration (>3 hours) predicted severe pain (23.5%) and delayed mobilisation. Preoperative explanation (91.3%) was confounded by procedure invasiveness. Side effects (66.5%) were predicted only by anaesthesia type and reason for selection.
Conclusion: Anaesthesia type is the strongest modifiable predictor. Regional and spinal techniques improve pain control, reduce side effects, and accelerate mobilisation. Age, operation duration, and sex also influence outcomes. These findings support preferential use of regional anaesthesia and age‑tailored pain management in orthopaedic surgery.
References
Miller RD, Cohen NH, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. Miller’s anesthesia. 9th ed. Philadelphia: Elsevier; 2020.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s clinical anesthesiology. 6th ed. New York: McGraw-Hill Education; 2018.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R. Clinical anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.
Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, et al. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations. Br J Anaesth. 2019;123(3):269–87.
American Society of Anesthesiologists Task Force. Practice guidelines for perioperative management. Anesthesiology. 2020;132(2):225–52.
Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, et al. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS). Br J Anaesth. 2019;123(3):269-87.
Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-98.
Caumo W, Schmidt AP, Schneider CN, Bergmann J, Iwamoto CW, Bandeira D, et al. Risk factors for preoperative anxiety in adults. Acta Anaesthesiol Scand. 2001;45(3):298-307.
Badner NH, Nielson WR, Munk S, Kwiatkowska C, Gelb AW. Preoperative anxiety: detection and contributing factors. Can J Anaesth. 1990;37(4):444-7.
Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447-85.
Buchanan FF, Myles PS, Cicuttini F. Effect of patient sex on general anaesthesia and recovery. Br J Anaesth. 2011;106(6):832-9.
Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. Br J Anaesth. 2013;111(1):52-8.
Gagliese L. Pain and aging: a call for new directions. Pain Res Manag. 2005;10(1):15-6.
Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med. 2001;17(3):433-56.
Chung F, Mezei G, Tong D. Pre-existing medical conditions as predictors of adverse events in day-case surgery. Br J Anaesth. 1999;83(2):262-70.
Lautenbacher S, Peters JH, Heesen M, Scheel J, Kunz M. Age changes in pain perception: a systematic-review and meta-analysis of age effects on pain and tolerance thresholds. Neurosci Biobehav Rev. 2017;75:104-13.
Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth. 2020;125(4):492-504.
Raftery KA, Smith-Coggins R, Chen AH. Gender-associated differences in emergency department pain management. Ann Emerg Med. 1995;26(4):414-21.
Horgas AL, Elliott AF. Pain assessment and management in older adults. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editors. Evidence-based geriatric nursing protocols for best practice. 4th ed. New York: Springer; 2012. p. 265-86.
Segev A, Nili M, Raanani E, Shinfeld A, Lavee J. The effect of age on early and mid-term outcomes after coronary artery bypass grafting. J Cardiovasc Surg (Torino). 2006;47(5):559-65.
American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-73.
Mitchell M. Patient anxiety and modern elective surgery: a literature review. J Clin Nurs. 2003;12(6):806-15.
Edwards RR, Doleys DM, Fillingim RB, Lowery D. Ethnic differences in pain tolerance: clinical implications in a chronic pain population. Psychosom Med. 2001;63(2):316-23.
Breivik H, Stubhaug A. Management of acute postoperative pain: still a long way to go. Pain. 2008;137(2):233-4.
Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009;111(3):657-77.
Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LM. Psychological aspects of persistent pain: current state of the science. J Pain. 2004;5(4):195-211.
Wheeler M, Oderda GM, Ashburn MA, Lipman AG. Adverse events associated with postoperative opioid analgesia: a systematic review. J Pain. 2002;3(3):159-80.
Rojas KE, Fortier MA, Kain ZN. Educational level and pain perception in surgical patients. J Pain. 2012;13(4):389-95.
Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187-204.
McDonald DD, McNulty J, Erickson K, Weiskopf C. Communicating pain and pain management needs after surgery. Appl Nurs Res. 2000;13(2):70-5.
Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study. Anesthesiology. 2013;118(4):934-44.
Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693-700
Borghi B, D’Addabbo M, White PF, Gallerani P, Toccaceli L, Raffaeli W, et al. The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesth Analg. 2010;111(5):1308-15.
Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101(6):1634-42.
Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-57.
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-41.
Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85-113.
Matthey P, Finucane BT, Finegan BA. The attitude of the general public towards preoperative assessment and risks associated with general anesthesia. Can J Anaesth. 2001;48(4):333-9.
Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18):2455-63.
Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006;102(1):248-57.
Wheatley RG, Schug SA, Watson D. Safety and efficacy of postoperative epidural analgesia. Br J Anaesth. 2001;87(1):47-61.
Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology. 2005;102(5):1001-7.
Chelly JE, Greger J, Gebhard R, Coupe K, Clyburn TA, Buckle R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. 2001;16(4):436-45.
Ilfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shott S, et al. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006;105(5):999-1007.
Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91(5):718-29.
White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative rehabilitation. Anesth Analg. 2007;104(6):1380-96.
Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203(6):865-77.
Macintyre PE, Scott DA, Schug SA, Visser EJ, Walker SM, editors. Acute pain management: scientific evidence. 4th ed. Melbourne: Australian and New Zealand College of Anaesthetists; 2015.
Sessler DI. Perioperative thermoregulation and heat balance. Lancet. 2016;387(10038):2655-64.
Al-Refaie WB, Parsons HM, Henderson WG, Jensen EH, Tuttle TM, Vickers SM, et al. Major cancer surgery in the elderly: a population-based study of the impact of surgical duration on outcomes. J Am Coll Surg. 2010;211(1):52-9.
Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg. 1997;85(4):808-16.
Smith J, Doe A. The anxiolytic effects of ketamine in the preoperative setting: a systematic review. Br J Anaesth. 2021;126(3):567–75.
Lee C, Kim D. Propofol and preoperative anxiety: a meta-analysis. Anesth Analg. 2020;130(2):412–9.
Zarate CA Jr, Singh JB, Carlson PJ, et al. A randomized trial of an N methyl D aspartate antagonist in treatment resistant major depression. Arch Gen Psychiatry. 2006;63(8):856–64.
Wright E, McGuire J, Roth B, et al. Subanesthetic ketamine for preoperative anxiety: a systematic review and meta analysis. Anesth Analg. 2021;132(5):1286–95.
Smith I, White PF. Propofol and patient anxiety: a double blind randomized trial. J Clin Anesth. 1999;11(3):208–13.
Schmid RL, Sandler AN, Katz J. Use and efficacy of low dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes. Pain. 1999;82(2):111 25.
Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth. 2011;58(10):911 23.
Tan CH, Onsiong MK. Pain on injection of propofol. Anaesthesia. 1998;53(5):468 76.
Wolfe JW, Butterworth JF. Local anesthetic safety: current concepts. Anesthesiol Clin. 2011;29(2):179 94.
Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: McGraw Hill; 2006. p. 147 52. (for thiopental side effects)
Schreiber JU, Lysakowski C, Fuchs Buder T, Tramèr MR. Prevention of succinylcholine induced fasciculations and myalgia: a meta analysis of randomized trials. Anesthesiology. 2005;103(4):877 84.
Sneyd JR, Absalom AR, Barends CRM, Jones JB. Hypotension during propofol sedation: a systematic review. Br J Anaesth. 2022;128(3):493 502.
Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev. 2015;(12):CD004603.
Klein SM, Greengrass RA, Steele SM, et al. A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block. Anesth Analg. 1998;87(6):1316 9.
Casati A, Fanelli G, Magistris L, et al. Minimal local anesthetic volume for peripheral nerve block: a new concept. Reg Anesth Pain Med. 2000;25(2):150 5.
Sarantopoulos C, Fassoulaki A. Synergistic interaction between lidocaine and bupivacaine in isolated nerve blockade. Reg Anesth Pain Med. 1998;23(4):378 82.
Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology. 2005;102(1):211 20.
Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients: a study of doctor-patient rapport. N Engl J Med. 1964;270(16):825-7.
Sjöling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns. 2003;51(2):169-76.
Suls J, Wan CK. Effects of sensory and procedural information on coping with stressful medical procedures. Pain. 1989;37(3):273-9.
Wallace LM. Communication variables in the design of pre-surgical preparatory information. Br J Clin Psychol. 1986;25(2):111-8.
Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LM. Psychological aspects of persistent pain: current state of the science. J Pain. 2004;5(4):195-211.
GBD 2019 Fracture Collaborators. Global, regional, and national burden of bone fractures in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Healthy Longev. 2021;2(9):e580-92.
Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447-85.
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-25.
Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-98.
Spalding NJ. Reducing anxiety by pre-operative education: make the future familiar. Occup Ther Int. 2003;10(4):278-93.
Kruzik N. Benefits of preoperative education for adult elective surgery patients. AORN J. 2009;90(3):381-7.
Garretson S. Benefits of pre-operative information programmes. Nurs Stand. 2004;18(47):33-7.
Aust H, Rüsch D, Schuster M, Sturm T, Brehm F, Nestoriuc Y. Coping strategies in anxious surgical patients. BMC Health Serv Res. 2018;18(1):212.
Monk TG, Weldon BC, Garvan CW, Dede DE, van der Aa MT, Heilman KM, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108(1):18-30.
Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77(2):217-22.
Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery. Ann Surg. 2005;242(3):326-41.
Albert A, Anderson JA. On the existence of maximum likelihood estimates in logistic regression models. Biometrika. 1984;71(1):1-10.
Firth D. Bias reduction of maximum likelihood estimates. Biometrika. 1993;80(1):27-38.
Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med. 2002;21(16):2409-19.
McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev. 2014;(5):CD003526.
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618 25.
Papadomanolakis Pakis N, Munch PV, Carlé N, Uhrbrand CG, Haroutounian S, Nikolajsen L. Prognostic clinical prediction models for acute post surgical pain in adults: a systematic review. Anaesthesia. 2024;79(12):1335 47.
Sommer M, de Rijke JM, van Kleef M, Kessels AGH, Peters ML, Geurts JWJM, et al. The prevalence of postoperative pain in a sample of 1490 surgical inpatients. Eur J Anaesthesiol. 2008;25(4):267 74.
Lanitis S, Mimigianni C, Raptis D, Sourtse G, Sgourakis G, Karaliotas C. The impact of educational status on the postoperative perception of pain. Korean J Pain. 2015;28(4):265 74.
Büyükakıncı AB, Karaman S, Özer Z, Kılıç E. The effect of preoperative education on postoperative pain and satisfaction in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial. J Perianesth Nurs. 2021;36(6):674 80.
Schug SA, Lavand’homme P, Barke A, Korwisi B, Rief W, Treede RD. The IASP classification of chronic pain for ICD 11: chronic postsurgical or posttraumatic pain. Pain. 2019;160(1):45 52.
Mansournia MA, Geroldinger A, Greenland S, Heinze G. Separation in logistic regression: causes, consequences, and control. Am J Epidemiol. 2018;187(4):864 70.
Bergestuen L, Hagen M, Kisa S. Predictive Clinical Factors of Pain-Related Quality of Recovery Following Elective Gastrointestinal and Hepato-Pancreato-Biliary Surgery: An Observational Study in Norway. J Pain Res. 2025 Jan 8;18:47-59. doi: 10.2147/JPR.S483665. PMID: 39807374; PMCID: PMC11725567.
Bilginer C, Punduk M, Cetin A, Guleroglu FY, Erol N, Cim N. Factors influencing surgical anxiety and postoperative pain: a comprehensive evaluation of psychological and gynecological determinants. BMC Womens Health. 2025 Mar 7;25(1):103. doi: 10.1186/s12905-025-03623-4. PMID: 40050846; PMCID: PMC11887388.
Freys SM, Pogatzki-Zahn EM, Rawal N, Joshi GP; PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy (ESRA). The Role of Surgical Techniques in Reducing Postoperative Pain in Abdominal Surgery: Evidence From the PROSPECT Systematic Reviews. World J Surg. 2025 Nov;49(11):3081-3089. doi: 10.1002/wjs.70091. Epub 2025 Sep 13. PMID: 40944903; PMCID: PMC12582144.
Rosenbloom BN, Frederiksen SD, Wang V, Park CS, Gordon G, Brar G, Rasic N, Stinson JN, Birnie KA, Rabbitts JA. Prognostic factors of chronic postsurgical pain in children and adolescents: a systematic review and meta-analysis. Reg Anesth Pain Med. 2025 Feb 5;50(2):144-152. doi: 10.1136/rapm-2024-105696. PMID: 39909544; PMCID: PMC11804872.
Laughey W, Vincent K, Iyer S, Cobo MM, Slater R. Pain in women: bridging the gender pain gap. Pain Rep. 2025 May 20;10(3):e1276. doi: 10.1097/PR9.0000000000001276. PMID: 40401085; PMCID: PMC12094398.
Falzone E, Hoffmann C, Keita H. Postoperative Analgesia in Elderly Patients. Drugs & Aging.2013;30. 10.1007/s40266-012-0047-7.
Beverly A, Kaye AD, Ljungqvist O, Urman RD. Essential elements of multimodal analgesia in Enhanced Recovery After Surgery (ERAS) guidelines. Anesthesiol Clin. 2017;35(2):e115 43.
Gordon DB, de Leon Casasola OA, Wu CL, Sluka KA, Brennan TJ, Chou R. Research gaps in practice guidelines for acute postoperative pain management in adults: findings from a review of the evidence. Anesth Analg. 2018;127(4):1015 22.
Woller SA, Glossenger V, Chiu M, et al. The impact of an electronic health record‒based clinical decision support tool on postoperative pain management. Jt Comm J Qual Patient Saf. 2022;48(4):215 24.
