Assessment of Postoperative Pain and its Management in Orthopedic Department in a Tertiary Care Hospital

Pain is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience related to actual or potential tissue damage or described in terms of such damage”. Acute postoperative pain is highly prevalent, with more than 80% of patients undergoing surgery experiencing pain and approximately 75% reporting moderate to severe intensity. Inadequately controlled postoperative pain can impair physical activity, sleep, psychological well-being, functional recovery, and overall quality of life. Therefore, systematic assessment and individualized pain management are essential components of postoperative care. Postoperative pain management generally involves a multimodal approach combining pharmacological interventions, including paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvant therapies, with appropriate non-pharmacological measures. However, individual variation in pain perception and response to treatment may result in persistent pain despite analgesic therapy. The present study was therefore undertaken to comprehensively assess postoperative pain using SF-MPQ and APS-POQ-R, evaluate the effectiveness of pharmacological and non-pharmacological pain-management strategies, identify commonly prescribed analgesics, and determine the impact of postoperative pain on physical activity, sleep, and emotional well-being among orthopaedic surgery patients.

OBJECTIVES

• To assess the intensity of postoperative pain in orthopaedic surgery patients using SF – MPQ study tool.
• To evaluate the effectiveness of pain management in reducing       postoperative pain.
• To assess mostly prescribed analgesics given for post-operative pain.
• To evaluate the pain severity and impact of pain on physical activity and emotional well-being using APS-POQ-R study tool.

MATERIALS AND METHODS

STUDY DESIGN

A prospective observational study was conducted.              

STUDY SITE

The study was conducted in the Orthopaedic department of a 450 bedded tertiary care hospital.

STUDY DURATION

The study was carried out for a period of 6 months.

STUDY POPULATION

A total of 123 patients.

STUDY CRITERIA

Inclusion Criteria

1. Patients of age group above 18.
2. Patients who underwent the orthopaedic surgery.
3. Patients who are able to understand the instructions.

Exclusion Criteria

1. The patients who were discharged before the 1^st 24 hour postoperatively.
2. Patients with cognitive disability, uncooperative patients and any difficulty with communication.
3. Patients undergoing surgeries other than in orthopaedic department.

STUDY APPROVAL

The study was started only after getting the approval from the Human ethical committee no

DATA COLLECTION AND ANALYSIS

Patient demographics, current complaints, analgesics prescribed, pain scores etc. is documented in a predesigned data entry form. SF-MPQ was used for the assessment of quality and intensity of pain. APS-POQ tool was used for assessing pain management quality improvement activities. The data were analyzed by various statistical methods such as mean, standard deviation using the software IBM SPSS 22.0 and presented graphically. We collected patient consent forms from the patients before the interview and questionnaire.

RESULTS AND DISCUSSIONS

A prospectively conducted observational study was performed in the Orthopaedic department of a 450-bedded tertiary care hospital for a duration of 6 months. The study was aimed to assess the intensity and severity of postoperative pain among orthopaedic surgery patients using the SF-MPQ and APS-POQ-R tools. The study was conducted in 123 post operative orthopaedic patients with the inclusion and exclusion criterion. Patient demographic characteristics, current complaints, analgesics prescribed, pain scores, and other relevant clinical information were recorded using a predesigned data collection form. The SF-MPQ was used to assess the quality and intensity of pain. The APS-POQ was used to assess the quality of pain management and identify areas for improvement in pain management practices. The collected data were analyzed using descriptive statistical methods, including mean and standard deviation, with IBM SPSS Statistics version 22.0. The results were presented graphically for better interpretation and comparison. Written informed consent was obtained from all patients prior to the interview and administration of the questionnaires.

Patient age was categorized into 4 groups. Among the 123 patients, the analysis of patient age revealed that the largest group of participants 32.5% (n=40) were between the ages of 51 and 70, followed by those between the ages of 31 and 50 of 31.7% (n = 39). This implies that the majority of musculoskeletal conditions requiring surgery affect middle-aged and older persons. Both the lower incidence of degenerative joint illnesses in younger populations and the reluctance or unsuitability of extremely senior patients for surgical operations may be reflected in the reduced percentage of patients aged ≤30 years (19.5%) and >70 years (16.3%).

TABLE 1: DISTRIBUTION BASED ON AGE OF PATIENTS (n=123)

The gender distribution of the 123 patients in the current study shows a small female predominance, with 53.6% (n=66) female participants and 46.4% (n=57) male participants, according to the patient data gathered. The risk of degenerative joint illnesses like osteoarthritis and the need for joint replacement surgery like complete knee or hip replacements rises in postmenopausal women as a result of the decline in estrogen levels. However, the nearly equal number of men and women suggests that musculoskeletal conditions are not highly gender-biased in terms of surgical need.

TABLE 2: DISTRIBUTION BASED ON GENDER OF PATIENTS(n=123)

In this study conducted among 123 patients, Only 22.8% (n=28) of patients reported acute pain, whereas 77.2% (n=95) of patients reported chronic pain. This suggests that the majority of patients requiring orthopedic surgery have chronic pain, most likely brought on by degenerative joint illnesses, recurrent trauma, or postponed medical treatment. Quality of life, psychological health, and sleep patterns are all known to be impacted by chronic pain, which highlights the importance of thorough pain assessment and treatment for these patients.

TABLE 3: DISTRIBUTION BASED ON TYPE OF PAIN (n=123)

According to pain score analysis, 57.8% of patients (n=71) in this study reported mild pain intensity (0–3), 34.1% (n=42) reported moderate pain (4–7), and only 8.1% (n=10) reported severe pain (7–9). This reveals that most the patients before the surgery were experiencing mild to moderate pain.

TABLE 4: DISTRIBUTION BASED ON PAIN SCORE BEFORE THE ORTHOPEDIC SURGERY (n=123)

The lower limb was the most frequently reported site of pain among the 123 patients about 56.9% (n=70), followed by the upper limb 24.4% (n=30) and hip 18.7% (n=23). Given that the lower extremities support the weight of the body and are more vulnerable to degenerative changes, trauma, and wear and tear. The emphasis on surgical procedures like total knee replacement and other lower extremity reconstructive surgery is justified by the prevalence of lower limb symptoms.

TABLE 5: DISTRIBUTION BASED ON LOCATION OF PAIN (n=123)

Only 4.1% (n=5) of the surgeries in this study were emergency procedures, whereas 95.9% (n=118) of the surgeries were elective. This demonstrates that most treatments are planned and regulated, enabling improved multidisciplinary planning, patient education, and preoperative optimization. The significance of early identification and scheduling for orthopedic disorders is reinforced by the fact that elective procedures are typically linked to better results and reduced rates of complications.

TABLE 6: DISTRIBUTION BASED ON TYPE OF SURGERY (n=123)

Among the 123 patients, only 10.6% (n=13) of patients received general anesthesia, compared to 89.4% (n=110) of patients who had regional anesthesia. Given its correlation with improved pain management, a decreased risk of respiratory problems, a quicker recovery period, and a decreased requirement for systemic analgesics after surgery, regional anesthesia is widely used in orthopedic surgery.

TABLE 7: DISTRIBUTION BASED ON TYPE OF ANAESTHESIA GIVEN(n=123)

In this study, given the high prevalence of degenerative joint disease and fractures, total knee replacement (TKR) was the most prevalent procedure 26.0% (n =32), closely followed by open reduction and internal fixation (ORIF) at 25.2% (n = 31). Hemiarthroplasty (9.8%), ACL repair (6.7%), K-wire fixation (4.9%), PFN fixation (4.1%), Fixator removal (4%), CRIF (3%), and THR (3%), were among the other common treatments. The wide range of orthopedic needs is shown by the existence of less usual procedures including Amputation, Arthrodesis, and Arthrolysis.

TABLE 8: DISTRIBUTION BASED ON SURGICAL PROCEDURE(n=123)

In this study the mechanism of injury classified into Slip and falls, Road traffic accident and age-related degeneration. The most commonly reported cause of injury among the 123 patients was46.4% (n = 57), followed by Slip and falls 31.7% (n=39) and Traffic accidents 21.9% (n=27). While road traffic accidents continue to be a major source of orthopedic trauma in younger groups, the large number of falls highlights the susceptibility of older persons.

TABLE 9: DISTRIBUTION BASED ON MECHANISM OF INJURY (n=123)

Fractures 69.1% (n=85) and osteoarthritis 27.7%(n=34) were the most common diagnosis, suggesting that degenerative illnesses and trauma are the two main causes of orthopedic surgery. Rheumatoid arthritis have low representation (0.8%) indicates that it is either less common or requires less frequent surgical treatment. The orthopedic departments' emphasis of joint replacement treatments and trauma care is supported by this diagnostic allocation.

TABLE 10: DISTRIBUTION BASED ON DIAGNOSIS (n=123)

With sensory and affective components average 11.57 and 4.86, respectively, patients' mean total pain score was 16.43 ± 3.59, suggesting a moderate level of discomfort with a noticeable emotional impact. A mean score of 6.55 on the visual analogue scale (VAS) indicated moderate pain. Effective pain management techniques are indicated by the mean pain intensity score of 1.07 (±0.80), which also emphasizes the need to address emotional reactions and lingering discomfort.

TABLE 11: MEAN AND STANDARD DEVIATION OF SHORT FORM McGILL PAIN QUESTIONNAIRE (SF-MPQ) (N=123)

Multiple qualitative descriptors were used by patients to describe their pain. They were most frequently Stabbing 96.7%(n=119), Tiring 95.1%(n=117), Aching 94.3%(n=116), and Sickening 93.5%(n=115), Throbbing 90.2%(n=111) followed by Heavy 88.6% (n=109), Shooting 87.8(n=108), Punishing 74.2%(n=92), Fearful 72%(n=89), and Sharp 63.4%(n=78) sensations. Descriptors typically associated with visceral or chronic pain, such as Hot-burning (30.1%), Cramping (15.4%), and Gnawing (15.4%), were reported less frequently. The least reported were Splitting 11.4% and Tender 8.1%. The broad spectrum of descriptions implies that pain is felt as an emotional and psychological burden in addition to a physical one.

TABLE 12: DISTRIBUTION BASED ON DESCRIPTORS OF PAIN (n=123)

Nausea, Drowsiness, Itching, Dizziness are the side effects of analgesics assessed; each is scored on a numeric rating scale from 1-3 mild,4-6 moderate, 7-10 severe. Nausea was a prominent side effect, affecting nearly half of the patients. While 40.7%(n=50) reported no nausea, a significant proportion 59.3%(n=73) experienced it to varying degrees. Notably, 22.8%(n=28) and 30.9% reported mild to moderate levels and 5.7%(n=7) experienced severe nausea. Drowsiness is one of the least reported side effect, with 26.8% of patients experiencing mild to moderate symptoms. However, the majority (73.2%) did not report any drowsiness. Itching was experienced by 44.7% of patients, with 34.1% reporting mild symptoms. While no patients reported severe itching. Dizziness was present in 43.1% of patients, with 15.4% experiencing moderate symptoms and one patient reporting severe dizziness. The findings highlight the importance of routine monitoring and individualized supportive care to mitigate adverse effects while ensuring adequate postoperative analgesia.

TABLE 13: DISTRIBUTION BASED ON SIDE EFFECTS(n=123)

Anxiety, fear (frightened), depression, and helplessness are among the emotional status assessed; each is scored on a numeric rating scale from 1-3 mild,4-6 moderate, 7-10 severe. About 54.5%(n=67) of patients were anxious, 38.2% (n=47) expressed mild anxiety but only 13.0%(n=16) and 3.3%(n=4) of respondents reported moderate and severe anxiety, respectively. Fright was also frequently reported, with 74.8% (n=92) of participants indicating some degree of fear. A substantial portion (26.8%) experienced moderate symptoms, while 4.1% reported severe fear. Depression, while less frequently reported than anxiety or fear, still affected 30.1% (n=37) of patients to some extent. Most cases were mild (26%), but a small number experienced moderate to severe depression. Helplessness was reported by 80.5% (n=99) of patients, with 47.2% experiencing moderate symptoms a notably high proportion. These results underscore the critical importance of incorporating psychological evaluation and support into postoperative care.

TABLE 14: DISTRIBUTION BASED ON EFFECT OF PAIN ON EMOTIONAL STATUS (n=123)

Pain significantly interfered with both out-off bed activities mean = 8.3, and in-bed activities, mean =7.1 as well as sleep mean =6.3. These findings highlight the multidimensional impact of pain on daily functioning and support the incorporation of functional outcome assessments in pain management protocols and also effective analgesia must target not only pain relief but also functional restoration and sleep quality.

TABLE 15: DISTRIBUTION BASED ON EFFECT OF PAIN ON ACTIVITY (n=123)

This table explains that the degree of pain being experienced by the patients in the first 24 hours postoperatively, individual differences in pain thresholds and experiences are suggested by the mean scores for least pain 3.5, worst pain 7, and severe pain 7.2. The low severe pain standard deviation 0.14 suggests that afflicted individuals consistently report high pain levels, in the first 24 hours postoperatively, highlighting the necessity of swift and forceful pain management during times of peak discomfort. 

TABLE 16: MEAN AND DEVIATION BASED ON PAIN DEGREE (n=123)

This table explains the intensity of pain experienced by patients, the majority of patients,71.5% (n=88) reported moderate pain, followed by severe pain 18.7%(n=23) and mild pain 8.1%(n=10) Merely 1.6% (n=2) did not feel any pain at all. This emphasizes the necessity of careful postoperative pain management and customized therapies, particularly for patients who report excruciating pain, since they are more likely to experience problems and experience a delayed recovery.

TABLE 17: DISTRIBUTION BASED ON INTENSITY OF PAIN (n=123)

Among 123 patients, all patients received 100% non-opioid analgesics, while 76.4%(n=94) of patients took opioids in combination with non-opioids. The relevance of multimodal analgesia in orthopedic settings to achieve efficient pain control while avoiding opioid-related side effects is highlighted by the extensive use of combination therapy.

TABLE 18: DISTRIBUTION BASED ON TYPE OF ANALGESICS USED (n=123)

99.2% (n = 122) of people utilized Paracetamol, confirming its use as a first-line painkiller. The next most popular medications. were Diclofenac 21.9%(n-27), Lornoxicam 17.9% (n-22), and Aceclofenac 15.4% (n-19), The comparatively reduced usage of mefenamic acid, pregabalin, and Flupirtine may be due to certain pain profiles or patient demands. These findings support the use of adjuvants and NSAIDs in the treatment of postoperative pain

TABLE 19: DISTRIBUTION BASED ON USAGE OF NON-OPIODS (n=123)

The most often used opioid was Tramadol 64.2% (n=79), which was followed by Fentanyl 36.6% (n=45) Pethidine 18.7% (n=23). In 16.2% of patients, Morphine was utilized, but Pentazocin was not. An attempt to offer long-lasting analgesia with fewer systemic adverse effects is indicated by the use of transdermal alternatives such as Zupinor patches (9.7%). Tramadol's domination is a result of its moderate potency and superior safety profile, which make it appropriate for a wide range of patients.

TABLE 20: DISTRIBUTION BASED ON USAGE OF OPIOIDS (n=123)

The table describes the patient's pain relief received from both medicine and non-medicine treatments, the vast majority of participants experienced significant pain relief, with 86.1% (n = 106) , reporting complete relief 70-100%, indicating high effectiveness of the interventions utilized. A smaller proportion, 13.1% (n = 16), experienced moderate relief (40-60%), while only 0.8% (n = 1) reported mild pain relief and 0% participants reported no pain relief. This pattern emphasizes the potential efficacy of the strategies or interventions applied, likely including both pharmacological and non-pharmacological modalities.

TABLE 21:   DISTRIBUTION BASED ON PAIN RELIEF (n=123)

In the distribution of pain-relieving non-medicinal techniques, Notably, 44.7% (n=55) of respondents did not use any non-medicinal method, which may imply either a strong reliance on medicinal methods or a lack of awareness/access to non-medicinal alternatives. Among those who did use non-medicinal options, cold packs were the most frequently employed 23.6%(n=29), followed by rest 13%(n=16), prayer 10.6%(n=13), and massage 8.1%(n=10).

TABLE 22: DISTRIBUTION BASED ON USAGE OF NON-MEDICINES (n=123)

CONCLUSION

This study reveals that postoperative pain is a prevalent concern among patients undergoing orthopedic surgery, with a significant number experiencing moderate to severe pain postoperatively.

The study concludes that majority of the patients experienced moderate to severe pain postoperatively.

While assessing the pain relief, it is found that a significant proportion was relieved from the pain management techniques.

Pain assessment tools such as the Short-Form McGill Pain Questionnaire (SF-MPQ) and APS-POQ-R were effectively utilized to evaluate both the quality and severity of pain and the impact on emotional and physical well-being.

The majority of patients (77.2%) reported chronic pain, with pain predominantly localized in the lower limb (56.9%) and described using pain descriptors such as stabbing (96.7%) and aching (94.3%).

Both opioid and non-opioid analgesics were widely used, with paracetamol (99.2%) and tramadol (64.2%) being the most frequently administered drugs, indicating a preference for multimodal pain management strategies.

The findings suggest that comprehensive pain management protocols, incorporating appropriate analgesic use and individualized pain assessment, are essential for improving postoperative outcomes and enhancing the overall quality of care in orthopedic patients.

CONFLICT OF INTEREST

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

ETHICAL CLEARANCE

The study protocol was reviewed and approved by the Institutional Ethics Committee (IEC). Written informed consent was obtained from all participants before data collection, and patient confidentiality was strictly maintained throughout the study.

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