International Journal of Surgery Open 27 (2020) 103e113

Contents lists available at ScienceDirect

International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Research Paper

Incidence and associated factors of post-operative pain after emergency

Orthopedic surgery: A multi-centered prospective observational cohort study
Nurhussen Riskey Arefayne a, *, Shimelis Seid Tegegne b, Amare Hailekiros Gebregzi a,
Salh Yalew Mustofa a
a
Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest, Ethiopia
b
Department of Anesthesia, College of Medicine and Health Sciences, Debretabor University, Debretabor, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Emergency orthopedic surgeries are performed on a daily and night basis across the world
Received 29 August 2020 and, different levels of postoperative pain is commonly reported early and late in the postoperative
Received in revised form period. Despite the availability of evidence-based international reports, still it is not clearly stated in
5 October 2020
Ethiopia.
Accepted 6 October 2020
Objective: To determine the incidence and associated factors of post operative pain after Emergency
Available online 10 October 2020
Orthopedics Surgery.
Methods: A multi-centered prospective observational cohort study was conducted to determine the
Keywords:
Emergency orthopedics surgery
incidence and associated factors of postoperative pain after emergency orthopedic surgeries from March
Incidence 1 to May 30, in 2020. Data was analyzed using Statistical Package for Social Sciences, version 20. To
Factors identify the association between outcome variable and independent variables, descriptive statistics, cross
Analgesia tabulation and binary logistic regression were used. Categorical data were analyzed using chi-square test.
Postoperative pain Adjusted odd ratios were computed with 95% confidence interval and p-value < 0.05 was used to
determine the significance of the study.
Result: The overall incidence of moderate to severe postoperative pain within the first 24 h after
emergency orthopedics surgery was 70.5% (95% CI: 64, 77). On multivariable logistic regression analysis;
history of having preoperative pain (AOR: 7.92, 95% CI: 3.04, 20.63), history of preoperative anxiety (AOR:
6.42, 95% CI: 2.59, 15.90), preoperative patient expectation about postoperative pain (AOR: 6.89, 95% CI:
2.66, 17.78) and being general anesthesia (AOR: 4.08, 95% CI: 1.30, 12.77) were significantly associated
with moderate to severe postoperative pain after emergency orthopedics surgery.
Conclusion: Postoperative pain management should be given a high priority in emergency orthopedics
surgery. Appropriate pain management strategy should be implemented to decrease postoperative pain
suffering. Factors associated with postoperative pain were; preoperative history of pain and anxiety,
patient expectation about postoperative pain and being general anesthesia.
© 2020 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction nature of trauma and surgical condition, which causes intense

In most developing countries like Ethiopia, trauma is a common
public health problem and it accounts for 25% of emergency sur-
gical cases [1]. Among those, majority of the surgical cases were
emergency orthopedic surgeries, which often associated with
moderate to severe postoperative pain. The reason is due to the
* Corresponding author.
E-mail addresses: nuizke@gmail.com (N.R. Arefayne), shemsu864@gmail.com
(S. Seid Tegegne), amaretom22@gmail.com (A.H. Gebregzi), salihyalew11@gmail.
com (S.Y. Mustofa).
nociceptive stimulation of the musculoskeletal tissue. It is also due
to inadequate postoperative analgesia and exposes patients to
postoperative pain [2,3] (see Tables 1e3).
Based on the international association for the study of pain, pain
is defined as ‘an unpleasant sensory and emotional experience
resulting from actual or potential tissue damage’ and acute pain is a
sudden onset which is expected to last within a short time. It is
clearly linked to a specific event, injury or illness. However; it is
usually multidimensional and involves sensory, affective and
cognitive processes (3). Untreated acute postoperative pain after
emergency orthopedics surgery will result in the development of

https://doi.org/10.1016/j.ijso.2020.10.003
2405-8572/© 2020 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al. International Journal of Surgery Open 27 (2020) 103e113

Table 1 and higher levels of pain severity. When assessing post-orthopedics

Perioperative anxiety assessment scale. surgery pain, the onset, location of pain, intensity of pain, aggra-
S.N Positive Not at all Somewhat Moderately Very much vating and relieving factors, previous treatment history, effect of
211 1. I feel calm 4 3 2 1
pain on physical function and barriers to pain assessment should be
2. I feel content 4 3 2 1 incorporated [7,12].
3. I am relaxed 4 3 2 1 Despite the fact that pain is a frequent reason for seeking
Negative medical attention, it is not assessed in ways consistent with current
4. I feel upset 1 2 3 4
practice recommendations, which hinders successful pain man-
5. I am tense 1 2 3 4
6. I am worried 1 2 3 4 agement. A study suggested that underestimation of pain up to 25%
and over estimation around 7% occurs by recovery health care
Total score
professionals despite the increasingly widespread practice of
Anxiety A. Yes routine screening. Persistent under recognition impairs progress in
B. No
improving the health-related quality of patient's life [13e15].
A systematic review has showed that the main reason for poor
management of painful conditions in the preoperative as well as in
chronic pain and its management strategy is more complex once postoperative period were; failure to acknowledge pain, failure to
developed [4]. As different studies reported, management of post- assess initial pain, failure to have pain management guidelines,
operative pain after orthopedics surgical procedures were chal- failure to document pain intensity, failure to assess treatment ad-
lenging compared to other types of operations and it needs equacy, and failure to meet patient's expectations [16e18].
different treatment options by health care professionals [5,6]. Lack of pain detection and poor advancements in the manage-
Poorly controlled acute postoperative pain is associated with ment of acute pain frequently reported in many hospitalized post-
increased morbidity, functional and quality-of-life impairment, emergency orthopedics surgical patients. This will result in hyp-
delayed recovery time, prolonged duration of opioid use, and oxia, ischemia, myocardial infarction, deep vein thrombosis, pul-
higher health-care costs. More effective analgesic measures in the monary embolism, pneumonia, insomnia, poor wound healing,
perioperative period are needed to prevent the progression to readmissions, and patient dissatisfaction. This also contributes to
persistent pain [7]. uncontrolled pain which in turn will lead to adverse physiological
From worldwide reports, moderate to severe levels of post- and psychological effects [19].
operative pain after orthopedics surgery is common. For instance; Management of postoperative pain should be a priority for the
in China it was reported to be 41 %e45% and in United States of surgical team because inadequate treatment of pain is associated
America 80e86%. At the same time; different degrees of post- with postoperative complications and poor outcomes [20]. Both
operative pain after emergency orthopedic surgeries are reported pharmacologic and the non-pharmacologic methods help to
in Africa and it is also a major unresolved problem. In South Africa manage postoperative pain. The non-pharmacologic methods can
the magnitude of postoperative pain showed that it was from 80 to be psycho educational care like reassurance, bed exercises
85% and in Tanzania 83.9 %- 100% [6,8e11]. involving breathing and coughing. The pharmacologic option of
Patients whose pain is caused by a specific orthopedics trauma postoperative pain management includes opioid analgesics, NSAID,
are differentiated from pain due to other causes by high level re- adjuvants, peripheral nerve blocks and neuraxial blocks [21,22].
ports of emotional stress, interference with normal life activities,
2. Methods
Table 2
Sociodemographic characteristics of the study participants (n ¼ 200) in both hos-
2.1. Study design
pitals, 2020.
Hospital based prospective follow up study design was con-
Variables Frequency(n) Percentage
ducted on the incidence and associated factors of post-operative
Age pain after emergency orthopedics surgery. This research article
18e29 years 83 41.5%
has been registered with UIN of research registry 5875.
30e59 years 90 45%
60 years and above 27 13.5%
BMI 2.2. Study area and period
Less than 18.5 kg/m2 44 22%
Between 18.5 and 24.9 kg/m2 122 61%
Greater than 24.9 kg/m2 34 17% This study was conducted at two comprehensive specialized
Gender hospitals in the PACU, ICU and orthopedic ward from March 1 to
Male 136 68% May 30, 2020.
Female 64 32%
We preferred to conduct our research in these two compre-
Occupational status
Unemployed 55 27.5% hensive specialized teaching hospitals to get adequate sample sizes.
Self employed 98 49% The residence population has the same demographic and patient
Private employee 32 16% characters. At the same time; both areas of study are teaching
Government employee 15 7.5% hospitals for medical specialty and comparable educational levels
Educational status
Illiterate 26 13%
of Anesthetists are working in those study areas.
Primary school 27 13.5%
Secondary school 57 28.5%
2.3. Source and study population
College and above 90 45%
Marital status
Single 72 36% 2.3.1. Source population
Married 109 54.5% All patients who have undergone any type of emergency trauma
Divorced 17 8.5% surgeries at both Comprehensive Specialized Hospitals operation
Widowed 2 1%
theatre were our source population.
104
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al. International Journal of Surgery Open 27 (2020) 103e113

Table 3
Preoperative Factors and their association with the response participants using cross tabulation in both hospitals, 2020.

Variables Frequency n (%) No to mild pain n (%) Moderate to severe pain n (%)

Gender
Male 136 (68) 40 (29.4) 96 (70.6)
Female 64 (32) 19 (29.7) 45 (70.3)
Age
18e59 years 174 (87) 52 (29.9) 122 (70.1)
60 years 26 (13) 7 (26.9) 19 (73.1)
ASA Status
ASA 1 154 (77) 44 (28.6) 110 (71.4)
ASA 2 and above 46 (23) 15 (32.6) 31 (67.4)
History of Preoperative anxiety
Yes 119 (59.5) 14 (11.8) 105 (88.2)
No 81 (40.5) 45 (55.6) 36 (44.4)
History of preoperative pain
Yes 112 (56) 11 (9.8) 101 (90.2)
No 88 (44) 48 (54.5) 40 (45.5)
Patient expectation on postoperative pain
No to mild pain 93 (46.5) 47 (50.5) 46 (49.5)
Moderate to severe 107 (53.5) 12 (11.2) 95 (88.8)
History of trauma related surgery
Yes 52 (26) 52 (100) 0 (0)
No 148 (74) 7 (4.7) 141 (95.3)
Other site soft tissue injury
Yes 60 (30) 59 (98.3) 1 (1.7)
No 140 (70) 0 (0) 140 (100)
Multiple site fractures
Yes 61 (30.5) 59 (96.7) 2 (3.3)
No 139 (69.5) 0 (0) 139 (100)

2.3.2. Study population nerve stimulator based), and postoperative levels of pain compared
All patients who have undergone emergency orthopedic surgery with expectation.
at operation theatres of both comprehensive teaching hospitals
within the study period were included. 2.6. Operational definition

2.4. Inclusion and exclusion criteria
2.4.1. Inclusion criteria
All emergency orthopedics surgical patients, age above 18 years
having orthopedic surgery under anesthesia during the study
period were included.
2.4.2. Exclusion criteria
Patients who were discharged before the first 24 h post-
operatively, Glasgow Coma Scale <14, documented cognitive
disability, uncooperative patients and any difficulty with commu-
nication were excluded.
2.5. Variables of the study
2.5.1. Dependent variables
Postoperative pain.
2.5.2. Independent variables
Socio-demographic variables: Age, Gender, BMI, occupation,
marital status, Educational status.
Preoperative patient related variables: ASA status, multiple
fracture, history of trauma related surgery, history of other site soft
tissue injury, preoperative history of analgesia intake, preoperative
history of anxiety, patient expectation about postoperative pain
and preoperative history of acute or chronic pain.
Intraoperative related variables: Duration of surgery, type of
surgery, intraoperative use of tourniquet, site of surgery, type of
anesthesia and duration of anesthesia.
Postoperative related factors: type of analgesics used post-
operatively, type of nerve blocks used with approach (blind Vs
105
Visual Analogue Scale: It is a pain assessment tool for
measuring subjective or behavioral phenomenon in which a subject
selects from gradient of alternatives as no pain to worst imaginable
pain arranged in linear fashion and measured with 100 mm ruler
and it is validated as no pain (0e5 mm), mild pain (6e40 mm),
moderate pain (41e74 mm), severe pain (75e100 mm) [24,45,46].
Based on VAS score; 0e5 mm ¼ No Pain, 6e40 mm ¼ Mild Pain
(nagging, annoying, interfering little with daily activity),
41e74 mm ¼ Moderate Pain (interferes significantly with daily
activity) and 75e100 mm ¼ severe pain (disabling; unable to
perform daily activity). Both VAS and NRS are most widely used,
reliable and valid pain assessment tools in the perioperative period.
However; NRS have been criticized as it doesn't provide ratio-level
scaling of pain. VAS pain assessment tool involves patients placed a
mark on the line at a point that best represented their pain to
provide an estimate of their pain. VAS has excellent statistical
properties, including ratio-level scaling [47]. For our data collection
purposes, with full explanation to the patient about the scoring
mechanism, we preferred VAS score as the main postoperative pain
assessment tool in our study.
Orthopedic injury is defined as an injury affecting the muscu-
loskeletal system, which includes injuries to bones, joints, liga-
ments, tendons, muscles, and nerves.
Orthopedics emergency is defined as a surgical condition that
should be done immediately by Orthopedician within 48 h of the
injury occurs, to prevent potential harm to the patient.
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al.
Postoperative pain is defined as pain that results in undesirable
feeling and discomfort, which arises from direct tissue trauma,
fracture or from secondary diseases process postoperatively [15].
Tolerable pain threshold: It is a treatment threshold of average
pain with a cut point of VAS score 40 mm, which was considered
to identify patients with pain of moderate-to-severe intensity [49].
Acute pain e Pain which occurs immediately after tissue injury,
for a short duration with the expectation that after a given length of
time the tissue heals and the pain resolves [41].
Multiple site fracture-defined as any types of fractures at two
or more sites of the musculo-skeletal system [11].
Anxiety refers to an overwhelming experience of fear, worry
and nervousness. This preoperative anxiety measurement scale is
valid and reliable assessment tool in Ethiopia. To get the total
anxiety scores; summing up all six scores and multiply by 20/6. If
the score above 20, preoperative anxiety confirmed [50].
2.7. Sample size calculation and sampling techniques
2.7.1. Sample size calculation
The sample size was determined using a single population
proportion formula. There is no study conducted in Ethiopia as well
in East Africa about incidence of postoperative pain on isolated
emergency orthopedics surgical patients. So; the Population pro-
portion value was taken as 0.5 ¼ , Q ¼ 1-p ¼ 0.5.
 
z f 2 2pq
= questionnaire was modified appropriately. Before surgery, patients
n¼
ε2
n ¼ is the desired sample size; z ¼ is standard normal distri-
bution usually set as 1.96 (corresponds to 95% confidence level);
p ¼ population proportion.
d ¼ degree of accuracy desired (marginal error is 5% (0.05));
then the sample size is calculated as follows:
n ¼ ð1:96Þ2ð0:50:5Þ
¼ 384.16 ¼ 385. The total number of opera-
ð0:05Þ2
tion performed annually is less than 10,000. So that; the final
sample size (nf) calculated by using reduction formula. nf ¼ n/
1 þ n/N,where N ¼ 340, the total number of Orthopedic emergency
operations done both in of the first and second comprehensive
teaching hospitals were 180 and 160 patients respectively.
The final sample size ¼ nf ¼ 385/1 þ 385/340 ¼ 180.5¼>181.
By adding 15% non-response rate; 181  15% ¼ 181 þ 27.15
¼ 208.15 ¼ 209.
2.7.2. Sampling technique
All consecutive patients undergoing emergency orthopedics
surgery under general anesthesia and regional blocks were
included in this study.
The incidence of postoperative pain and its associated factors
were assessed after 2 h, 12 h and 24 hrs of operation in the PACU,
recovery room, and orthopedics ward. At the same time; periop-
erative types of analgesia and regional block as well as total opioid
consumption were assessed.
2.8. Data collection procedure
Before data collection, four BSc anesthetists were selected for
data collection at both setups. Then after; training had been given.
The data collection procedures include chart review and interview-
based questionnaire. The data collectors assessed the pain severity
at 2, 12, 24 h postoperatively using VAS at rest and movement
through direct interview. The supervisor controlled the data quality
and its completeness at the end of data collection for each partic-
ipant in the first hospital. Where as one of the data collectors act as
106
International Journal of Surgery Open 27 (2020) 103e113
a supervisor in the second teaching hospital to check completeness
and quality of data.
2.8.1. Data collection tools
A pre-tested and semi-structured questionnaire about the
incidence and associated factors of postoperative pain after emer-
gency orthopedics surgery was prepared by the investigator and
Visual Analogue Scale was incorporated as part of postoperative
pain assessment tool with time interval of 2 h, 12 h and 24 h after
surgery. Patients were shown how to score their pain using a visual
analogue scale prior to the surgical procedures. From the chart
information like patients’ age, sex, ASA status, type of procedure,
diagnosis, type of analgesics given and duration of surgery were
drawn. Additional information was obtained through direct patient
interview.
The data collection procedures were continued for consecutive 90
days. Data about postoperative pain were collected from a total of 200
emergency orthopedics patients (98 patients from the first hospital
and 102 patients from the second setup) with 95.7% response rate.
2.9. Data quality management
Pre-test of the data collection was done on 5% of the calculated
sample size. These patients were not included in the main study
and the collected data were checked out for the completeness,
accuracy and clarity by the principal investigator. After pre-test, the
were instructed in the VAS score for the purpose of effective pain
assessment. Finally; data were cleaned up and cross-checking was
done before analysis.
2.10. Data analysis and interpretation
Epi-Info software version 7.2.2 was used for data entry and SPSS
version 20 was used for data analysis. Model fitness was checked by
Hosmer and lemeshow goodness of fit. After analysis, data were
expressed as mean ± standard deviation for normally distributed
data. Non-normally distributed data were presented as median and
interquartile range for quantitative variables as count and percent.
The association between the outcome variable and independent
variables were assessed using binary logistic regression. Those vari-
ables with p-values of less than 0.2 on binary logistic regression were
entered to multivariable regression. Categorical data were performed
by chi-square test. Tables and graphs were used for a descriptive
purpose. 95% confidence interval and p-values were computed and a
p-value of <0.05 was considered as statistically significant.
3. Result
A total of 200 emergency orthopedics patients have been
included in this study based on the inclusion criteria with a 95.7%
response rate. The data were collected from the first setup 102
(51%) and 98 (49%) from the second teaching comprehensive hos-
pital. Nine patients were excluded from analysis due to incomplete
data.
3.1. Sociodemographic characteristics of the study participants
The median and IQR for both age and body mass index of the
study participants were 33 [26,31,32,37e43,45e47] and 22.3
(18.73e24.20) respectively. The majority of orthopedics surgical
patients were between the age of 18e59 years 173 (87%) and body
mass index between the ranges of 18.5e24.9 kg/m2 122 (61%).
Majority of the cases were male in gender 136 (68%), whereas fe-
male accounts only 64 (32%).
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al. International Journal of Surgery Open 27 (2020) 103e113

3.2. Preoperative factors 3.5. Regional nerve blocks for orthopedics surgery

As the preoperative factors distribution showed the majority of
patients were ASA I 154 (77%). Hypertension accounts 18 (9%),
Diabetes mellitus 16 (8%), Asthma 6 (3%) and Retroviral infection
accounts 6 (3%).
3.3. Preoperative emergency surgical indications and intraoperative
procedures
Among the major causes of presentation, motor vehicle acci-
dent accounts 60 (30%), followed by bullet injury 49 (24.5%). Fail
down injury accounts 38 (19%), infection 28 (14%), stick injury 19
(9.5%) and machine crash in 6 (3%) of cases. Tibio-fibular fracture
was the commonest preoperative diagnostic presentation in 37
(18.5%) of orthopedics cases. Femoral shaft fracture was the
second most post-traumatic long bone fracture in 34 (17%) of
surgical cases. Radio-ulnar fracture accounts 26 (13%), Dry and
wet Gangrene 26 (13%), Osteomyelitis and Arthritis 16 (8%),
Humeral shaft fracture 12 (6%), Patellar fracture 12 (6%), Ankle
joint dislocation 11 (5.5%), elbow dislocation 9 (4.5%), Clavicular
fracture in 5 (2.5%), wrist joint dislocation 5 (2.5%), knee joint
dislocation 4 (2%) and hip joint dislocation 3 (1.5%) of cases. The
majority of the procedures were debridement in 66 (33%) of
cases. Both internal and external fixation accounts 51 (25.5%),
Amputation 29 (14.5%), Sequestrectomy and Arthrotomy 16 (8%),
plating 15 (7.5%), Closed reduction 8 (4%), open reduction 9
(4.5%), and Debridement with pin traction diagnosed in 6 (3%) of
cases (see Tables 4e6).
3.4. Intraoperative factors
Large proportions of emergency orthopedic patients had un-
dergone surgery under spinal anesthesia 98 (49%), while 80 (40%)
patients done under general anesthesia. The remaining 22 (11%)
patients were done under peripheral nerve blocks.
Lower extremity procedures cover the majority of orthopedic
surgeries 134 (67%). Whereas; upper extremity procedures cover 61
(30.5%) and chest procedures 5 (2.5%) of cases. The durations of
surgery for majority of patients completed within one up to 3 h 129
(64.5%) whereas; the duration of Anesthesia was prolonged for
more than 3 h in 95 (47.5%) of orthopedics surgical patients (see
Figs. 1 and 2).
To alleviate post orthopedics surgical pain, peripheral nerve
blocks usually recommended. Still these types of postoperative
pain management options were poorly practiced for emergency
patients. Only 25% of patients had got postoperative pain control
using peripheral nerve blocks. From the different types of nerve
blocks; sciatic nerve blocks practiced in 11 (5.5%) patients and
axillary nerve blocks done for 23 (11.5%) patients. Other majority of
cases 150 (75%) didn't get peripheral nerve block based post-
operative pain management options.
3.6. Postoperative analgesics given
Commonest analgesics drugs given during 2 h postoperatively
were Diclofenac 78 (39%), tramadol 56 (28%), PCM 2 (1%), pethidine
2 (1%) and nerve block 2 (1%). Others 60 (30%) of patients haven't
got any types of analgesics with in the first 2 h postoperatively.
Mechanism of multimodal analgesics: Multimodal analgesia is
the combination of analgesics. When NSAID combined with opi-
oids, they produce significant opioid dose-sparing effects and re-
sults in better pain relief at lower doses of each analgesic than
would be possible with any single analgesics. Opioids binds on
opioid receptors to act in the central and peripheral nervous system
to block neurotransmitters that facilitate pain transmission, local
anesthetics relieve pain by blocking nerve conduction, and NSAID
inhibit prostaglandins that facilitate pain transmission [51]. How-
ever; majority of our study participants were treated with a single
analgesic approaches of postoperative pain management tech-
niques. This will contribute for the increased in postoperative
pain complain after emergency orthopedics surgery in our study
participants.
3.7. Incidence of postoperative pain
In our study, the first 2 h after surgery Visual analogue scale
shows that 127 (63.5%) of emergency orthopedics surgical patients
experienced no to mild pain whereas 73 (36.5%) reported as
moderate to severe postoperative pain.
The 12 h's VAS postoperative pain report shows that 123
(61.5%) of patients reported to have no to mild pain, whereas 77
(38.5%) of patients reported moderate to severe pain (see Figs. 3
and 4).

Table 4
Intraoperative factors and their association with postoperative pain using cross tabulation in both hospitals, From March to May 30, 2020.

Variables Frequency n (%) Postoperative 24 h' patients pain score

No to mild pain n (%) Moderate to severe pain n (%)

Site of surgery
Upper extremity 61 (30.5) 14 (23) 47 (77)
Lower extremity 134 (67) 42 (31.3) 92 (68.7)
Chest 5 (2.5) 3 (60) 2 (40)
Size of surgical incision
<5 cm 35 (17.5) 9 (25.7) 26 (74.3)
5e10 cm 82 (41) 26 (31.7) 56 (68.3)
>10 cm 83 (41.5) 24 (28.9) 59 (71.1)
Type of anesthesia
General Anesthesia 80 (40) 6 (7.5) 74 (92.5)
Spinal Anesthesia 120 (60) 53 (44.2) 67 (55.8)
Duration of surgery
<1 h 43 (21.5) 9 (20.9) 34 (79.1)
1e3 h 129 (64.5) 41 (31.8) 88 (68.2)
>3 h 28 (14) 9 (32.1) 19 (67.9)
Duration of Anesthesia
Less than 1 h 12 (6) 2 (16.7) 10 (83.3)
1e3 h 93 (46.5) 22 (23.7) 71 (76.3)
Greater than 3 h 95 (47.5) 35 (36.8) 60 (63.2)

107
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al. International Journal of Surgery Open 27 (2020) 103e113

Table 5
Perioperative analgesics given for our study participants and their association with postoperative pain using cross tabulation in the first 24 h in both hospitals, 2020.

Variables Frequency n (%) No to mild pain n (%) Moderate to severe pain n (%)

Preoperative analgesics
Not given 147 (73.5) 43 (29.3) 104 (70.7)
Systemic Analgesics given 53 (26.5) 16 (30.2) 37 (69.8)
Intraoperative analgesics drugs
Not given 106 (53) 32 (30.2) 74 (69.8)
Systemic analgesics given 94 (47) 27 (28.7) 67 (71.7)
Immediate 2 h postoperatively
Not given 60 (30) 19 (31.7) 41 (68.3)
Systemic analgesics given 138 (69) 38 (27.5) 100 (72.5)
Nerve blocks 2 (1) 2 (100) 0 (0)
12 h postoperative period
Not given 51 (25.5) 15 (29.4) 36 (70.6)
Systemic analgesics given 149 (74.5) 44 (29.5) 105 (70.5)
Analgesics Immediately 24 h postoperatively
Not given 55 (27.5) 15 (27.3) 40 (72.7)
Systemic analgesics given 145 (72.5) 44 (30.3) 101 (69.7)
Comparison of postoperative levels of pain after Postoperative nerve blocks
Not given 150 (75) 40 (26.7) 110 (73.3)
Nerve blocks done 50 (25) 19 (38) 31 (62)

Table 6
Bivariable and multivariable logistic regression showing factors associated with postoperative pain after Emergency Orthopedics surgery, at both hospitals from March to May,
2020.

Variables Postoperative pain within 24 h Odd Ratio with 95% CI P-values

No to mild pain n (%) Moderate to severe pain Crude (95% CI) Adjusted (95% CI)

n (%)

History of preoperative Anxiety

Yes 14 (11.8) 105 (88.2) 9.37 (4.61,19.05) 6.42 (2.59,15.90) P < 0.001
No 45 (55.6) 36 (44.4) 1.00 1.00
History of preoperative pain
Yes 11 (9.8) 101 (90.2) 11.02 (5.20,23.33) 7.92 (3.04,20.63) P < 0.001
No 48 (54.5) 40 (45.5) 1.00 1.00
Patient's expectation about postoperative pain
No to mild pain 47 (50.5) 46 (49.5) 1.00 1.00
Moderate to severe pain 12 (11.2) 95 (88.8) 8.08 (3.91,16.70) 6.89 (2.66,17.78) P < 0.001
Intraoperative tourniquet used
Yes 3 (8.8) 31 (91.2) 5.26 (1.54,17.96) 4.34 (0.79,23.68) P ¼ 0.089
No 56 (33.7) 110 (66.3) 1.00 1.00
Type of Anesthesia
General Anesthesia 6 (7.5) 74 (92.5) 9.75 (3.94,24.15) 4.08 (1.30,12.77) P ¼ 0.016
Regional Anesthesia 53 (44.2) 67 (55.8) 1.00 1.00
Duration of Anesthesia
<1 h 2 (16.7) 10 (83.3) 1.00 1.00
1e3 h 22 (23.7) 71 (76.3) 1.54 (0.31,7.61) 0.59 (0.06,5,29) P ¼ 0.639
>3 h 35 (36.8) 60 (63.2) 0.53 (0.28,1.00) 0.50 (0.19,1.31) P ¼ 0.162

Hosmer and Lemishow goodness of fit test ¼ 0.779.

The 24 h's postoperative pain VAS score shows that the number
of participants who reported to have no to mild pain were 142
(71%), where as those patients who developed moderate to severe
pain were 58 (29%).
Based on the results of this study; the overall incidence of
moderate to severe postoperative pain within the first 24 h was
70.5% (95% CI: 64, 77) after emergency orthopedics surgery.
3.8. Factors associated with postoperative pain after emergency
orthopedics surgery
Using Bivariable logistic regression analysis; history of pre-
operative anxiety, history of preoperative pain, preoperative pa-
tient expectation about postoperative pain, intraoperative use of
tourniquet, type of anesthesia and duration of anesthesia were
significant. However; using Multivariable logistic regression
analysis; history of having preoperative pain, preoperative anxi-
ety, patient expectation about postoperative pain and being
108
general anesthesia were significantly associated with moderate
to severe postoperative pain after emergency orthopedics
surgery.
Based on this research result; orthopedics patients who had
preoperative anxiety were 6.42 times more likely to develop
moderate to severe postoperative pain compared with those pa-
tients who were not anxious (AOR: 6.42, 95% CI: 2.59, 15.90).
Similarly; the odds of having moderate to severe postoperative
pain for patients who had history of preoperative pain were 7.92
times more likely to develop moderate to severe postoperative pain
compared with those who had no history of preoperative pain
(AOR: 7.92, 95% CI: 3.04, 20.63).
Our study also showed that orthopedics surgical patients who
had expected postoperative pain as moderate to severe before
operation were 6.89 times more likely to develop moderate to
severe postoperative pain compared to patients who expect
postoperative pain as no to mild pain (AOR: 6.89, 95% CI: 2.66,
17.78).
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al. International Journal of Surgery Open 27 (2020) 103e113

Fig. 1. Regional nerve blocks done before and soon after emergency orthopedics surgery for the study participants (n ¼ 200) in both hospitals, 2020.

Fig. 2. The percentage of specific analgesics given within the first 24 h postoperative period after emergency orthopedics surgery in both hospitals, 2020.

Fig. 3. The first 2 h, 12 h and 24 h's cumulative pain reports of patients after emergency orthopedics surgery respectively (n ¼ 200) at both hospitals from March to May, 2020.

At the same time; orthopedics surgical patients who had done
under general anesthesia were 4.08 times more likely to develop
moderate to severe postoperative pain compared to patients done
under regional anesthesia intraoperatively (AOR: 4.08, 95% CI: 1.30,
12.77).
4. Discussion
The purpose of our study was to determine the incidence and
associated factors of post-operative pain and to see their associa-
tion with socio demographic factors, preoperative and

109
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al.
Fig. 4. Conceptual frame work on factors associated with postoperative pain after emergency orthopedics surgery, extracted from literature review, at both hospitals, 2020.
intraoperative factors as predictors of postoperative pain after
emergency orthopedics surgery.
Based on the finding of our study, the overall incidence of
moderate to severe postoperative pain within 24 h after emergency
orthopedics surgery was 70.5% (95% CI: 64, 77). The three-time
interval incidence of moderate to severe postoperative pain
shows 36.5% within the first 2 h, 38.5% after 12 h and 29% after 24 h
of emergency orthopedics surgery. Accordingly, postoperative pain
was undermanaged after emergency orthopedics surgery, in both
comprehensive specialized hospitals.
Different previously conducted studies have revealed that
postoperative pain management was inadequate and still high
in different areas of the world with the incidence between 20%
and 80% after orthopedics surgery [53]. Our study shows similar
and consistent result with a study done in Jordan on 275 or-
thopedics surgical patients, which reported that the incidence of
moderate to severe postoperative pain after orthopedics surgery
was 72% [54].
A longitudinal studies done in USA, showed that the incidence of
moderate to severe postoperative pain in orthopedics surgery was
80% within the first 24e48 h postoperatively [31,55]. Based on the
above study, the incidence of postoperative pain was higher
compared to the findings of our study. The possible explanation for
this variation is, the above study has large sample size compared to
our study and they have followed and studied the incidence of up to
48 h of postoperative time. The reason for lower incidence of pain
in our study compared to the above study might be due to a relative
110
International Journal of Surgery Open 27 (2020) 103e113
small sample size and the types of surgery were less extensive and
short duration compared to surgeries done in USA [56].
A study done in Norway shows that the incidence of moderate to
severe postoperative pain were 60% after orthopedics surgery [57].
It is slightly lower than our finding. This might be due to having
good pain assessment and pain management practices using pa-
tient controlled analgesia in their study areas [42]. The possible
reason for the increase in incidence in our study might be due to
limited use of effective analgesic drugs and poor practice of
regional blocks for orthopedics surgical patients [58].
In line with our study; high prevalence of moderate to severe
postoperative pain was also reported from longitudinal study done
in Netherland, which was 71% after general and orthopedics sur-
gery (24). The above study has used larger numbers of sample sizes
to reach into their conclusion and this will much more strengthen
our study results. However; the above study included emergency
abdominal surgery in addition to emergency orthopedic surgeries.
Another longitudinal study done in Tanzania on 136 patients
shows that the incidence of moderate to severe postoperative pain
after orthopedics surgery were 100%, 83.9% and 36% after 12,24 and
48 h postoperative period respectively [56]. The result of the above
study was too much higher compared with our report, which was
38.5% at 12 h and 29% at 24 h after surgery. The possible explana-
tion for too much increased in incidence from above report might
be; most of the surgical patients were at higher pain intensity level
before operation that results in a decreased in the postoperative
pain threshold level and the presence of poor pain management
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al.
practice in the above study areas [59]. As different study shows
multimodal approach pain management system is the best way to
treat orthopedic surgical pain [43]. Still the problem is common in
our study areas even if the incidence is lower compared to above
study. The possible explanation for the decreased incidence of pain
in our study areas might be, most of the emergency orthopedics
surgical patients in our setup were done under regional anesthesia
which resulted in prolonged postoperative pain relief and a pro-
longed analgesia request time.
Our study result found that orthopedics surgical patients who
had preoperative anxiety were 6.42 times more likely to develop
moderate to severe postoperative pain compared to those patients
without preoperative anxiety. This result is consistent with a study
done in Spain showed that patients who had preoperative anxiety
were 4.6 times more likely to develop moderate to severe post-
operative pain compared with patients without preoperative anx-
iety, with the incidence rate of 72% [2]. The possible reason for
association between anxiety and pain is explained by synergistic
effects of psychological factors on biological response which results
in difficulty in treatment options [46].
This study result on association between preoperative anxiety
and early moderate to severe postoperative pain after orthopedics
surgery is also supported by another study done in USA, which
revealed that there was positive association with an odd ratio of
1.54 and 95% CI [40]. Based on the above study; the incidence of
anxiety associated with severe postoperative pain after orthopedics
surgery was 56%.whereas; in our study the incidence of anxiety
associated moderate to severe postoperative pain was 59.5%.
Presence of preoperative anxiety, which leads to the release of
chemical mediators from the injury site, the adrenal cortex, and the
immune system, all of which, in turn, interact with mediators of
pain in the postoperative period [3].
In our study; orthopedics surgical patients who had preopera-
tive pain were 7.92 times more likelihood of developing moderate
to severe postoperative pain. As studies support, our result have
high consistency with an observational study, which reported as a
strong association of preoperative pain with postoperative persis-
tent pain with odd ratio of 2.42 and 95% CI [60]. At the same time; a
prospective study done in France on 109 patients reported that
presence of untreated moderate to severe preoperative pain were
associated with postoperative pain after orthopedics trauma pa-
tients [37,61]. This is due to synergistic effects and a decrease in
pain threshold in the postoperative period [43].
Our study is supported by a cohort study done in Australia
showed that patients who had preoperative pain were 1.17 times
more likely to develop postoperative pain compared to those pa-
tients who had no preoperative pain with 95% [32]. Based on the
result of this study, the incidence of moderate to severe post-
operative pain within the first 2 h was 56% and it was decreased to
16% after 24 h. In comparison to our study, the incidence was higher
in the first 2 h and lower in 24 h' post-orthopedics surgery. The
possible explanation for decrement of postoperative pain in the
above study might be clinicians adopted a multimodal approach to
intra- and postoperative analgesia, aimed at addressing nociceptive
and inflammatory responses [62]. Pain is recognized not only as a
sensory experience but also as a phenomenon with affective and
cognitive components. Factors such as previous pain experiences
play a role in determining an individual's perception of pain [63].
Our study result revealed that; patient's preoperative expecta-
tion towards postoperative pain showed strong association. Or-
thopedics trauma patients who had expected moderate to severe
postoperative pain before operation were 6.89 times more likely to
develop pain postoperatively compared with those who expected
post-surgical pain as no to mild pain. As different literature sup-
ports this result, a study done in USA on 82 patients reported that
111
International Journal of Surgery Open 27 (2020) 103e113
patients who expected actual postoperative pain as moderate to
severe preoperatively had 2.00 times more likelihood of developing
moderate to severe acute pain compared with patients an average
expected postoperative VAS pain score of less than 40 mm (95% CI:
1.1, 3.5) [38]. Our study is also supported by a study done in
Netherland, which showed that patients who expected their
postoperative pain with VAS score greater than or equal to 40 mm
were 2.12 times more likely to develop pain within the first post-
operative day (95% CI: 1.61,2.78) [60].
Another comparative study done in USA between patient
expectation and physician's prediction about the levels of actual
postoperative pain showed that; physicians tends to under-
estimated the levels of patient's pain compared to patients. This
study also concludes that discussion about expectations of post-
operative pain should be done by patient's own decision making,
not by physicians. It shows significant association with actual
postoperative pain levels [39,64]. It was also found that patient
satisfaction with postoperative pain management relies on pa-
tients' expectations, the intensity of pain experienced, promptness
of acute pain service response and effectiveness of treatment [26].
The result of our study also shows that orthopedics surgical
patients who had done under general anesthesia were 4.08 times
more likely to develop moderate to severe postoperative pain
compared with patients who operated under regional anesthesia.
This report is supported by a study done in Brazil on 98 patients
which showed that; patients done under general anesthesia were
9.5 times more chance of developing postoperative pain compared
to regional anesthesia with 95% CI (3.3, 30.0) [65]. By considering
the difference in the types of surgeries, a hospital based cross
sectional study done on 150 elective orthopedics and general sur-
gical patients showed that general anesthesia was the independent
contributing factor for postoperative pain with AOR of 5.56. After
2 h’ postoperative period 70% of patients done under general
anesthesia developed moderate to severe postoperative pain
compared to 29% of spinal anesthesia group patients. However;
after 12 h of postoperative period, 85% of patients done under
spinal anesthesia feel moderate to severe postoperative pain
compared with 75% general anesthesia group of patients. This was
due to underestimation of postoperative pain in spinal anesthesia
patients by health professionals [58]. Another study in UK on 40
patients also revealed that the severity of postoperative pain
significantly decreased within the first 4e6 h after regional anes-
thesia postoperatively. But; there was no significant difference in
postoperative pain levels after 6 h of postoperative time between
general anesthesia and regional anesthesia groups [66]. This might
be due to the small numbers of sample size they used. The differ-
ence in postoperative pain level is explained by prolonged effective
pain relieving mechanisms of regional blocks on the pain trans-
mission pathway [67].
Our study also supported by a prospective follow up study in
Portugal showed that patients who have done under general
anesthesia were more likely to develop moderate to severe post-
operative persistent pain than orthopedics surgical patients done
under regional anesthesia [68].
At the same time; another prospective observational study done
in Nigeria supported our study. The study showed that most of
orthopedics patients done under regional anesthesia had minimal
or no pain when severity of pain was assessed first postoperative
day after surgery. As the study result showed, from regional anes-
thesia group more than 80% had numeric pain score of zero to
three. None of patients had severe pain when assessed post-
operatively and about 80% of those patients who experienced pain
had a single dose of opioids within the first 24 h after surgery
[6,69]. Even though; they used small sample size compared to our
study, which was only 25 orthopedics cases, still it strengthens our
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al.
study and it concludes that being general anesthesia increases the
severity of postoperative pain incidence.
5. Strength and limitations of our study
5.1. Strength of our study
This research is designed to identify incidence and factors
associated with postoperative pain within the first 24 h after
emergency orthopedics surgery. It is a very important field of study
in which relatively little research has been done previously.
5.2. Limitation of the study
One of the limitations of this study is, it was better if patients
done under general anesthesia and regional anesthesia groups
were stated alone. Another limitation of our study was heteroge-
neous orthopedics surgical procedures and lack of control group.
6. Conclusion
In our study, we have found that the overall incidence of mod-
erate to severe postoperative pain after emergency orthopedics
surgery was 70.5% in both comprehensive specialized hospitals.
Therefore; Clinicians need to prioritize postoperative pain
assessment and analgesics prescription at early 24 h following or-
thopedics surgery to minimize pain. Factors associated with post-
operative pain after emergency orthopedics surgery were
preoperative history of pain and anxiety, patient expectation about
postoperative pain and exposure to general anesthesia.
7. Recommendations
Based on the results of our study; we would like to suggest the
following recommendations.
7.1. For PACU coordinators and clinicians
Expected to facilitate the practice of regional blocks and assure
availability of analgesic drugs as parts of multimodal analgesia for
emergency orthopedics surgery.
7.2. For orthopedics ward nurses and physicians
Asses the severity of postoperative pain and try to treat post-
operative pain based on available analgesics and communicate with
other pain medicine physicians or with anesthetists.
7.3. For hospital management
They need take in to consideration that the magnitude of the
problem is high and plan for serious measurements either by
mobilizing resources or scaling up the knowledge of the clinicians
involved in the care of such patients by training and other mech-
anisms about pain assessment and management options.
7.4. For researchers
We recommend interested researchers to do further more
detailed studies on this area with large sample size and longer
follow up time, up to 48 h of postoperative time with comparative
group.
112
International Journal of Surgery Open 27 (2020) 103e113
Ethical approval
The ethical approval was obtained from ethical review com-
mittee of University of Gondar with reference number of 1934/03/
2020.
Funding
University of Gondar.
Author contribution
This work was carried out by the collaboration of all authors. S.S.
Tegegne contributed to the conception and design of the study,
acquired, analyzed and interepted the data drafted and revised the
manuscript. N.R. Arefayne, A. H. Gebregzi, and S.Y. Mustofa partic-
ipated in reviewing the design and methods of data collection,
interpretation and preparation of the manuscript. All authors
participate in preparation and critical review of the manuscripts. In
addition, all authors read and approved the manuscript.
Guarantor
Shimels Seid Tegegne (S.S. Tegegne), Nurhessen Riskey Arefayne
(N.R. Arefayne), Amare Hailekiros Gebregzi (A.H. Gebregzi), Salh
Yalew Mustofa (S.Y. Mustofa).
Research registration unique identifying number (UIN)
5875.
Conflict of interest statement
There is no conflict of interest among the participants of the
research article.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ijso.2020.10.003.
References
[1] Bashah DT, Dachew BA, Tiruneh BT. Prevalence of injury and associated factors
among patients visiting the Emergency Departments of Amhara Regional
State Referral Hospitals, Ethiopia : a cross-sectional study. BMC Emerg Med
2015:1e7 [Internet].
[2] Robleda G, Sillero-sillero A, Puig T, Gich I. Influence of preoperative emotional
state on postoperative pain following orthopedic and trauma surgery
2014;22(5).
[3] Sloman R. Original articles determination of clinically meaningful levels of
pain reduction in patients experiencing acute postoperative pain. Pain Manag
Nurs 2006;7(4):153e8.
[4] Mscn MB, Candidate CD, Practice A. Acute to chronic pain transition in ex-
tremity trauma : a narrative review for future preventive interventions (part
1). Int J Orthop Trauma Nurs 2016;23:47e59.
[5] Bot AGJ, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture
surgery correlates with pain intensity and satisfaction with pain relief. 2014.
[6] Rocchi A. Regional Anesthesia and Pain Canadian survey of postsurgical pain
and pain medication experiences, vols. 1053e6; 2002.
[7] Holmes A, Med M, Williamson O, Hogg M, Dip G, Arnold C, et al. Predictors of
pain severity 3 Months after, vols. 990e1000; 2010.
[8] Zhi-qiang W, Si-yan Z, Fransen M, Jian-hao LIN. Original article 2012;125(14):
2499e504.
[9] Li RJ, Li ML, Leon E, Ng CWK, Shindo M, Manzione K, et al. Comparison of
opioid utilization patterns. JAMA Otolaryngol-Head Surg 2018;97239(11):
1060e5.
[10] Willingham M, Rangrass G, Curcuru C, Abdallah A Ben, Wildes TS, Mckinnon S,
et al. Association between postoperative complications and lingering post-
surgical pain : an observational cohort study. Br J Anaesth 2019;(October):
1e8 [Internet].
N.R. Arefayne, S. Seid Tegegne, A.H. Gebregzi et al.
[11] Haonga BT, Makupa JE, Muhina RI, Nungu KS. Pain management among adult
patients with fractures of long bones at Muhimbili Orthopaedic Institute in
Dar es Salaam. Tanzania J Health Res 2011;13(4).
[12] Montane
E, Vallano A, Vidal X, Aguilera C, Laporte J. Reporting randomised
clinical trials of analgesics after traumatic or orthopaedic surgery is inade-
quate : a systematic review. BMC Clin Pharmacol 2010.
[13] Shugarman LR, Goebel JR, Lanto A, Asch SM, Sherbourne CD, Lee ML, et al.
Nursing staff, patient, and environmental factors associated with accurate
pain assessment [Internet] J Pain Symptom Manag 2010;40(5):723e33. 4.
[14] Tomaszek L. Knowledge , compliance with good clinical practices and barriers
to effective control of postoperative pain among nurses from hospitals with
and without a “Hospital without Pain” certificate. 2018. November 2017.
p. 1641e52.
[15] Christian K, Centre M. Postoperative pain management outcomes among
adults treated at a tertiary hospital in Moshi. Tanzania 2014;16(1).
[16] Motov SM. Problems and barriers of pain management in the emergency
department : are we ever going to get better? J Pain Res 2009:5e12.
[17] Kopp LTJA, Anderson LTAB, Dickens LTCJF, Wang LJM, Highland KB. Ortho-
pedic surgeon decision-making processes for postsurgical opioid prescribing.
2019. p. 1e6. 00.
[18] Ashton-james CE, Bloemers F. Protocols for treating the postoperative pain of
fractures in Dutch hospitals, vols. 635e9; 2013.
[19] Gregory J, Mcgowan L. An examination of the prevalence of acute pain for
hospitalised adult patients : a systematic review. 2016. p. 583e98.
[20] Chaibou MS, Sanoussi S, Sani R, Toudou NA, Daddy H, Madougou M, et al.
Management of postoperative pain : experience of the niamey national hos-
pital , Niger. 2012.
[21] Abou-setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP. Review annals
of internal medicine comparative effectiveness of pain management in-
terventions for hip Fracture : a systematic review. 2011.
[22] Gessner DM, Horn J, Lowenberg DW. Pain management in the orthopaedic
trauma patient : non-opioid solutions [Internet] Injury 2019. https://doi.org/
10.1016/j.injury.2019.04.008. Available from:.
[24] Sommer M, De Rijke JM, Van Kleef M, Kessels AGH, Peters ML, Geurts JWJM,
et al. Original Article the prevalence of postoperative pain in a sample of 1490
surgical inpatients, vols. 267e74; 2008.
[26] Shoqirat N, Mahasneh D, Al-khawaldeh O, Singh C. Pain management nursing
postoperative patients in Jordan : pain prevalence, characteristics, beliefs, and
satisfaction. Pain Manag Nurs 2019;20(3):239e44 [Internet].
[31] Grodofsky SR, Sinha AC. The association of gender and body mass index with
postoperative pain scores when undergoing ankle fracture surgery.
J Anaesthesiol Clin Pharmacol 2014;30(2):248e53.
[32] Edgley C, Hogg M, De Silva A, Braat S, Bucknill A, Leslie K. Severe acute pain
and persistent post-surgical pain in orthopaedic trauma patients : a cohort
study. Br J Anaesth 2019;123(3):350e9 [Internet].
[37] Thomazeau J, Rouquette A, Martinez V, Rabuel C, Prince N, Laplanche JL, et al.
Acute pain Factors predictive of post-operative pain and opioid requirement
in multimodal analgesia following knee replacement. Eur J Pain
2016;20(September 2015):822e32.
[38] Bayman EO, Parekh KR, Keech J, Larson N, Weg M Vander, Brennan TJ. Pre-
operative patient expectations of postoperative pain are associated with
moderate to severe acute pain after VATS. 2018. 0(June):1e12.
[39] Rosenberger PH, Jokl P, Cameron A, Ickovics JR, et al. Predictions and Ratings
of Knee Surgery Outcomes 2005;21(5):562e9.
[40] Raichle KA, Osborne TL, Jensen MP, Ehde DM, Smith DG, Robinson LR. Pre-
operative state anxiety , acute postoperative pain, and analgesic use in per-
sons undergoing. Lower Limb Amputation 2015;31(8):699e706.
[41] Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to
the prescription opioid epidemic in orthopedic surgery. Anesth Analg
2017;125(5):1704e13.
[42] Gan TJ. Poorly controlled postoperative pain : prevalence, consequences, and
prevention. 2017. p. 2287e98.
113
International Journal of Surgery Open 27 (2020) 103e113
[43] Hospital S. Postoperative pain management and the risk factors in major
Operation : a baseline study of acute pain service. Siriraj Hosp 2016;99(5):
549e56.
[45] Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and
verbal rating scales for the assessment of postoperative pain in orthopedic
patients. J Pain Symptom Manag 1999;18(6):438e46.
[46] Collins SL, Moore RA, Mcquay HJ. The visual analogue pain intensity scale :
what is moderate pain in millimetres? Pain 1997;72:95e7.
[47] Fillingim RB. Individual differences in pain responses. 2005.
[49] Lee WC, Zhang M, Mak AF, Wc AL, Zhang M, Regional MAF. Regional differ-
ences in pain threshold and tolerance of the transtibial residual Limb :
including the effects of age and interface Arch Phys Med Rehabil. Archiv Phys
Med Rehabilit 2005;86(April):641e9.
[50] Kayikcioglu O, Deveci A, Bilgin S, Seymenoglu G. State and trait anxiety scores
of patients receiving intravitreal injections. 2017. p. 478993.
[51] Pasero C, Mccaffery M. Orthopaedic postoperative pain management. 2007.
p. 160e74.
[53] Radinovic K, Milan Z, Markovic-denic L, Dubljanin-raspopovic E, Jovanovic B,
Bumbasirevic V. Predictors of severe pain in the immediate postoperative
period in elderly patients following hip fracture surgery. Injury 2014;45(8):
1246e50 [Internet].
[54] Massad IM, Mahafza TM, Attyyat BA, Almostafa MM. Postoperative pain is
undertreated : results from a local survey at Jordan University Hospital, vols.
485e9; 2010.
[55] Svensson I, Sjo €stro
€m B, Haljama €e H. Assessment of pain experiences after
elective surgery. J Pain Symptom Manag 2000;20(3):193e201.
[56] Mwashambwa MY, Yongolo IM, Kapalata SN, Meremo AJ. Post-operative pain
prevalence, predictors, management practices and satisfaction among oper-
ated cases at a Regional Referral Hospital in Dar es Salaam. Tanzan J Health
Res 2018;20(2):1e8.
[57] Lindberg MF, Grov EK, Gay CL, Rustøen T, Granheim TI, Amlie E. Pain char-
acteristics and self-rated health after elective orthopaedic surgery e a cross-
sectional survey. J Clin Nurs 2013;(1242):1242e53.
[58] Ethiopa N, Admassu WS, Hailekiros AG, Abdissa ZD. Severity and Risk Factors
of Post-Operative Pain. J Anesth Clin Res 2016;7(10).
[59] Article O. Pre and postoperative analgesia for orthopedic surgeries *. Revista
Dor 2015;16(3):166e70.
[60] Sommer M, De Rijke JM, Van Kleef M, Kessels AGH, Peters ML, Geurts JW, et al.
Predictors of acute postoperative pain after elective surgery. Clin J Pain 2010;26(2).
[61] Veal FC, Bereznicki LRE, Thompson AJ, Peterson GM, Orlikowski C. Subacute pain
as a predictor of long-term pain following orthopedic surgery an Australian
prospective 12 Month observational cohort study. Medicine 2015;94(36):1e6.
[62] Kankkunen P, Ja €nis P, Vehvil€
ainen-julkunen K. Pain assessment among non-
communicating intellectually disabled people described by nursing staff,
vols. 55e9; 2010.
[63] Acute pain following musculoskeletal injuries and orthopaedic surgery. 2005.
[64] Ri A. Perceptions of pain levels among orthopedic surgery patients, their
relatives, and nurses. 2015. 27(July):132e138.
[65] Article O. General anesthesia is predictive for occurrence of postoperative
pain. 2020. 1e5.
[66] Nesek-adam V, Schwarz D, Grizelj-stoj E, Ra D. The effect of spinal versus
general anesthesia on postoperative pain and analgesic requirements in pa-
tients undergoing peripheral vascular surgery. Coll Antropol 2012;36:1301e5.
[67] Allen D, Beaule
PE. Prevalence of associated deformities and hip pain in pa-
tients with cam-type femoroacetabular impingement. J Bone Jt Surg Br Vol
2009;91(5):589e94.
[68] Luís D, Lourenc H, Araújo I, Fonseca S. Pain after major elective orthopedic
surgery of the lower limb and type of anesthesia : does it matter? Rev Bras
Anestesiol 2016;66(6):628e36.
[69] Yunus AA, Nwasor EO, Idris ME, Ejagwulu FS. Regional analgesia for post-
operative pain management e initial experience in a low resource setting.
East Afr Med J 2012;89(3):100e5.