ORIGINAL ARTICLE

Does Regional Anesthesia Improve the Quality of

Postoperative Pain Management and the Quality of
Recovery in Patients Undergoing Operative Repair
of Tibia and Ankle Fractures?
Nabil Elkassabany, MD, MSCE, Lu Fan Cai, MD, Samir Mehta, MD, Jaimo Ahn, MD, PhD,
Lauren Pieczynski, MD, Rosemary C. Polomano, PhD, RN, FAAN, Stephanie Picon, BS,
Rosemary Hogg, MD, and Jiabin Liu, MD, PhD

Objectives: To determine whether the use of peripheral nerve

blocks (PNBs) as part of an analgesic protocol for operative repair of
tibia and ankle fractures can improve the quality of postoperative
pain management and the quality of recovery (QOR).

Study Design: Prospective cohort study.

Setting: Orthopedic trauma service in an academic tertiary care
center.

Patients: Ninety-three consecutive patients undergoing operative

repair of fractures of the ankle and tibia.

Intervention: Administration of popliteal and saphenous nerve

blocks, as part of postoperative analgesia regimen in some patients.
Patients were labeled as the regional group or the no-regional group
based on whether they received PNBs.
Outcomes: Patient satisfaction and the quality of pain management
were measured 24 hours after surgery using the Revised American
Pain Society Patient Outcome Questionnaire. The QOR was
measured at 24 and 48 hours after surgery using the short version
of the Quality of Recovery Questionnaire (QOR-9).
Results: Satisfaction with pain management was signicantly
higher (P = 0.005) in the regional group when compared with the
no-regional group. Average pain scores over 24 hours was similar
between the 2 groups (P = 0.07). The regional group reported less
time spent in severe pain over 24-hour period (40 vs. 50%, P =
0.04) and higher overall perception of pain relief (80 vs. 65%, P =
0.003). Patients receiving regional anesthesia also demonstrated
Accepted for publication March 27, 2015.
From the Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA.
Presented in part at the Annual Meeting of the American Society of Regional
Anesthesia, April 4, 2014, Chicago, IL.
The authors report no conict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.jorthotrauma.com).
Reprints: Nabil Elkassabany, MD, MSCE, University of Pennsylvania,
3400 Spruce St, Dulles 6, Philadelphia, PA 19104 (e-mail: nabil.
elkassabany@uphs.upenn.edu).
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better QOR measured by the QOR-9 at 24 hours (P = 0.04) but

not at 48 hours (p = 0.11).

Conclusions: Patient satisfaction and the quality of postoperative

pain management for the rst 24 hours were better in patients who
received PNBs as part of their postoperative analgesic regimen when
compared with patients who received only systemic analgesia.
Key Words: regional anesthesia, peripheral nerve block, pain management, orthopedic trauma, trauma, ankle fracture, tibia fracture

Level of Evidence: Therapeutic Level II. See Instructions for

Authors for a complete description of levels of evidence.
(J Orthop Trauma 2015;29:404409)

INTRODUCTION
Regional anesthesia (RA) has been shown to improve
postoperative pain control, provide site-specic analgesia,
and decrease opioid-related adverse effects when compared
with opioid-based analgesia protocols.15 Peripheral nerve
blocks (PNBs) have long been underused for acute pain management in orthopedic trauma.6 Associated side effects, time
required to perform the blocks, and lack of the expertise
necessary to provide RA are some of the potential reasons
for not providing PNBs on a large scale for orthopedic trauma
patients.7 Common concerns expressed within the orthopedic
trauma community include delayed ability to monitor postoperative nerve function and masking or delaying the diagnosis of acute compartment syndrome.8,9 Critics argue that the
impact of PNBs on patient outcomes is yet to be proven in the
setting of orthopedic trauma.6 Pain scores, total amount of
opioids used, and the frequency of opioid-related side effects
have been traditionally the focus of most research studies
comparing the effect of regional techniques to different analgesic modalities.10
Assessment of patient-centered outcomes is becoming
exceedingly important especially in the era of pay-forperformance and value-based purchasing programs.11 These
outcomes include patient satisfaction, quality of pain management, and the quality of recovery (QOR) after surgery.11
Health care organizations frequently use patient satisfaction
ratings as an integral part of marketing and benchmarking of
J Orthop Trauma  Volume 29, Number 9, September 2015

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J Orthop Trauma  Volume 29, Number 9, September 2015

services. Patient satisfaction may also be used as an indicator of quality care and as an incentive for health care
providers.12,13 The need to measure, compare, and improve
the quality of postoperative pain management is increasingly
sought by health care consumers, payers, and professionals. The Affordable Care Act created several pay-forperformance programs that reduce Medicare reimbursement
to hospitals that score below national performance benchmarks on selected quality measures.14 Reimbursement to
hospitals will depend, in part, on the results of their Hospital
Consumer Assessment of Healthcare Providers and Systems
survey results. Pain management is one of the 9 key items
included in the survey where a subset of patients rates their
hospital experience and their pain management from their
perspective.14
Assessment of the quality of pain management mandates looking beyond the traditional pain outcomes. The
Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults has been published by the
American Pain Society (APS) in 2010 to address this need.15
The questionnaire (see Figure, Supplemental Digital Content
1, http://links.lww.com/BOT/A368) assesses the quality of
postoperative pain management in 5 domains: (1) pain severity
and sleep interference, (2) interference with activity, (3) severity of adverse effects, (4) affective subscale, and (5) patient
perception and satisfaction with their care.
QOR has also been recognized as an important patientoriented outcome and has been correlated with other measures
of health-related quality of life in the postoperative period.16 It
has been used to measure and compare the impact of different
perioperative interventions on patient health status.
This study aims to determine if the use of PNBs as part
of the analgesic protocol for operative repair of tibia and
ankle fractures can improve patient satisfaction with pain
management, the quality of postoperative pain management,
and the QOR. We hypothesized that the use of PNBs as part
of the analgesic protocol for operative repair of tibia and
ankle fractures can improve the quality of postoperative pain
management and the QOR.

PATIENTS AND METHODS

This prospective cohort study was approved by the
Institutional Review Board at the University of Pennsylvania. Patients admitted by the orthopedic trauma service with
isolated tibial or ankle fractures and undergoing operative
repair, between the ages of 18 and 80, were eligible for
enrollment. Exclusion criteria included multisystem or limb
trauma, pregnancy (age ,18 years), and allergy to local
anesthetics or any of the study medications. Patients who
were deemed by the surgeon to be at high risk for development of acute compartment syndrome or at risk of nerve
injury were also excluded. Patients meeting inclusion criteria during the study period were approached to participate in
the study before obtaining the anesthesia consent. Patients
were operated on by 1 of 2 orthopedic trauma surgeons
(S.M., J.A.). All patients received general anesthesia, with
or without ultrasound-guided nerve blocks of the sciatic
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Regional Anesthesia for Single Extremity Fractures

nerve at the popliteal fossa, and the saphenous nerve in

the adductor canal. Popliteal nerve blocks were performed
using 2030 mL of Ropivacaine 0.5%. Saphenous nerve
block was performed by injecting 1020 mL of Ropivacaine
0.5%, lateral to the femoral artery in the adductor canal. The
choice of the block was based on a discussion between the
surgeon and the anesthesiologist based on the distribution
of sensory coverage of each block. Offering PNBs, as part
of postoperative analgesia protocol, depended on availability of a member of the RA team at the time of surgery.
Patients who received PNBs were labeled regional group.
Patients who did not receive PNBs were labeled noregional group.
The APS-POQ-R was used to measure patient satisfaction with postoperative analgesia and the quality of pain
management. A research assistant blinded to the use of PNBs
administered the questionnaire 24 hours after surgery to
evaluate patient satisfaction with postoperative pain relief.
We also measured the quality of patients recovery using the
QOR-9 (see Figure, Supplemental Digital Content 2, http://
links.lww.com/BOT/A369) at 24 and 48 hours. The QOR-9 is
a 9-item questionnaire that was validated in previous studies.17 Other data collected include fracture type, patient demographics, postanesthesia care unit length of stay, and hospital
length of stay. Study data were collected and managed using
the Research Electronic Data Capturing tool (REDCap).18
REDCap is a secure web-based application designed to support data capture for research studies.

Sample Size
A pilot study of 27 patients receiving systemic analgesia
for ankle fracture showed a mean satisfaction score of 6 with
SD of 2.3. To show 25% improvement in the score of patient
satisfaction with postoperative analgesia, from 6.0 to 7.5 (onesided test), a signicance level of 0.05, and 80% power, 30
patients per group needed to be enrolled in the study.

Statistical Analysis
Statistical analysis was performed using Stata (version
11 software package; STATA Corp, TX). Demographic data
are presented as mean values 6 SD for continuous data or as
actual frequencies for categorical data. Answers to the questions of the APS-POQ-R and the QOR-9 are presented as
medians and interquartile ranges. Demographic data were
analyzed using Student t test or chi-square test as appropriate.
MannWhitney U test was used to compare the questionnaire
results between the 2 primary cohorts. The a level for all
analyses is set as P , 0.05. Pearson correlation was conducted to study the relationship between patient satisfaction
and other independent variables. Satisfaction with pain management was compared based on gender and diagnosis of
chronic pain using the MannWhitney U test.

RESULTS
Between January, 2013, and April, 2014, 104 patients
met inclusion criteria and were approached to participate in
the study. Eleven patients declined to participate, leaving 93
patients (59 regional, 34 no-regional) who agreed to the study.
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J Orthop Trauma  Volume 29, Number 9, September 2015

Elkassabany et al

The consort ow diagram shows patient enrollment of the

study (see Figure, Supplemental Digital Content 3, http://
links.lww.com/BOT/A370). Fifty-four patients in the regional
group received both popliteal and saphenous nerve blocks, and
the remaining 5 patients received an isolated popliteal nerve
block. Patients demographics were comparable (Table 1).
Patient satisfaction score was signicantly higher (P =
0.005) in the regional group, 9 (710), when compared with
the no-regional group, 7 (69). Table 2 summarizes the results
of the APS-POQ-R. Patients in the regional group received
more information about different options for pain management
and believed that they were allowed to participate in the decision making regarding their postoperative pain management
more than the no-regional group (P = 0.03 and 0.02). The sum
of adverse effects and the impact of pain on negative emotions
were signicantly higher in the no-regional group when compared with the regional group (P = 0.02 and 0.018, respectively). Least, average, and worst pain score in the 24-hour
period was lower in the regional group (Fig. 1). The average
and least pain scores were not signicantly different between
the 2 groups (P = 0.07 and 0.09, respectively). However, the
median of the worst pain score in 24 hours was signicantly
lower in the regional group (9 vs. 10, P = 0.04). The noregional group reported a median higher percentage of time
spent in severe pain (50%) when compared with the regional
group (40%), P = 0.04. Patients in the no-regional group were
ordered intravenous patient-controlled analgesia (IV PCA) as
a supplement to postoperative analgesia more frequently than
patients in the regional group (19/35 vs. 19/59, P = 0.03).
Subgroup analysis of ankle versus tibia fractures is summarized in (see Table, Supplemental Digital Content 4, http://
links.lww.com/BOT/A367).
Patients receiving RA also demonstrated better QOR as
measured by the QOR-9 questionnaire at 24 hours and 48
hours (Fig. 2). The QOR-9 score in the regional group, 13
(1114), was signicantly higher at 24 hours (P = 0.04) when
compared with the no-regional group, 13 (1214). QOR-9
score after 48 hours did not differ signicantly (P = 0.11):

TABLE 2. Summary of the Results of the APS-POQ _R

No-regional
Pain severity and relief
Least pain in the rst 24 h
Worst pain in the rst 24 h
Average pain in the rst 24 h
Percentage of time in severe
pain in the rst 24 h (%)
How much pain relief in the
rst 24 h (%)
Impact of pain on activity, sleep
How much pain interfered with
activity in bed
How much pain interfered with
activity out of bed
How much pain interfered with
falling asleep
How much pain interfered with
staying asleep
Affective subscale
How much pain affect mood
and emotion (sum of
negative emotions: anxiety,
depression, fear,
helplessness)
Side effects of the treatments
Sum of the score of adverse
effects (nausea, drowsiness,
itching, dizziness)
Perception of care and
helpfulness of information
Participation in the decision
making
Percentage of pain relief over
24 h (%)
Satisfaction scores with the
pain management
Did you receive information
about pain treatment options
(yes/total)

4.5
10
7
50

(26)
(910)
(58)
(2080)

Regional
3
9
5
40

(05)
(610)
(37)
(070)

0.09
0.04*
0.07
0.04*

65 (5080)

80 (6090)

0.003*

9 (610)

5 (09)

0.0017*

9 (510)

7 (110)

0.26

5.5 (110)

5 (09)

0.3

7 (410)

2 (08)

0.01*

13.5 (725)

9 (218)

0.018*

13 (819)

13 (523)

0.02*

8.5 (510)

10 (810)

0.02*

70 (5080)

80 (6090)

0.006*

7 (69)

9 (710)

0.005*

21/34

48/59

0.03*

Data are presented as median (IQR), unless otherwise indicated.

*Signicant if P , 0.05.

TABLE 1. Patients Demographics

No-regional

Regional

Age, mean (SD), y

51.5 (14.7)

0.14

Gender (males/total)
Race (white/total)
BMI, mean (SD)
PACU length of stay, mean
(SD), min
Diagnosis of chronic pain
(chronic pain/total)
Hospital LOS, mean (SD), d
Fracture type
Ankle fracture
Tibia fracture
Total

17/34
21/34
30.3 (10.9)
126 (82.3)

46.5
(16.8)
28/59
30/59
30.1 (6.4)
114 (98)

0.8
0.3
0.9
0.56

(5/35)

(9/59)

0.8

7.6 (7.4)

4.6 (4.7)

18
16
34

33
26
59

0.02*

*Signicant if P , 0.05.
BMI, body mass index; LOS, length of stay; PACU, postanesthesia care unit.

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the regional group scored 14 (1216), whereas the noregional group score was 16 (1317).
The relationship between satisfaction scores and different variables was further studied using Pearson correlation
and direct comparison between patient groups. Correlation
coefcients and P values for different variables are displayed
in Table 3. Predictors signicantly correlated with higher
satisfaction scores were the percentage of overall pain relief,
participation in the decision making, and QOR score at 24
hours. Patients who received information regarding options
for postoperative patient management had higher satisfaction
score, 9 (710), than those who did not receive similar information, 7 (69) (P = 0.03). However, the sum of negative
emotions and percentage of time spent in severe pain were
negatively correlated with satisfaction with pain management
(P = 0.001 and 0.002, respectively). Satisfaction scores in
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J Orthop Trauma  Volume 29, Number 9, September 2015

Regional Anesthesia for Single Extremity Fractures

TABLE 3. Summary of the Results of Pearson Correlations

Between Satisfaction Score and Different Variables
Variable Names

FIGURE 1. Bar graph of pain intensity and patient satisfaction

score in both groups (regional and no-regional). Error bars
represent IQR. IQR, interquartile ranges. Editors note: A color
image accompanies the online version of this article.

patients with chronic pain, 9 (610), were not signicantly

different from those without the diagnosis, 8 (610) (P = 0.9).
These scores were also similar between males, 7 (69), and
females, 9 (710) (P = 0.06).

DISCUSSION
Our results demonstrate that patients who had PNBs as
part of their analgesic protocol had higher satisfaction scores
and scored better in 3 of the 5 domains assessed by the APSPOQ-R questionnaire, namely perception of care, side effects
of treatment, and affective subscale. To our knowledge, this
study is the rst to assess the quality of postoperative pain
management in orthopedic trauma patients using the APSPOQ-R. Measurement of pain scores and opioid requirements
only provide limited information on the quality of care.
Assessment of the overall quality of pain management and
understanding the impact of pain management on patients
QOR and satisfaction should be used to guide clinical practice.
The regional group had a better QOR when assessed 24
hours after surgery. At 48 hours, the QOR score was not

FIGURE 2. Bar graph of QOR-9 results in both groups. Error

bars represent IQR. IQR, interquartile ranges. Editors note:
A color image accompanies the online version of this article.
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Percentage of time spent in severe

pain
Overall percentage of pain relief in
24 h
Participation in decision making
regarding options for pain
management
Sum of the negative emotions
Sum of the adverse effects of
treatment
QOR-9 at 24 h
QOR at 48 h
Age
BMI

Correlation Coefcients

20.3

0.002*

0.6

0.001*

0.4

0.001*

20.3
20.1

0.001*
0.16

0.4
0.16
0.1
0.05

0.001*
0.11
0.3
0.6

*Signicant if P , 0.05.
BMI, body mass index.

signicantly different from the no-regional group. The QOR

is a patient-related health status measure that was developed
for postoperative patient assessment.19 In this study, we used
the short version of the questionnaire (QOR-9). It has been
shown to be valid, reliable, and simple to use in routine
clinical practice.17 Our results have shown that QOR score
at 24 hours was positively correlated with higher patient satisfaction with postoperative pain management. Myles et al20
have shown similar relationship in a prospective study of
10,811 inpatients seen on the rst postoperative day. However, the authors cautioned that assessment of the relationship
between satisfaction and the QOR may lead to inclusion bias
as each scale may be measuring similar aspects of health
status, and thus they are likely to be associated.
In this study, all patients underwent general anesthesia. Details of the anesthetic management were left to the
discretion of the anesthesia team. Jordan et al showed that
spinal anesthesia is associated with better pain scores and
better total scores on the American Orthopedic Foot and
Ankle Society outcome instrument at 3 and 6 months after
surgery when compared with general anesthesia. However,
this association did not persist at 12 months.21
A research assistant blinded to PNBs administered the
survey questionnaires 24 hours after surgery. At this point,
the effect of the single-shot PNB should have resolved. The
timing of survey administration may explain why the
medians of the average pain scores more than 24 hours in
our survey were not different between the 2 groups (7 vs. 5
for the no-regional vs. regional group, respectively; P =
0.07). However, patients in the regional group scored better
on questions about the overall pain relief, patient satisfaction, and their perception of their pain management protocol.
Multimodal analgesia is used whenever feasible in the
orthopedic trauma patients in our hospital. Elements of the
analgesia protocol include acetaminophen, gabapentin, and
systemic opioids (oral and as needed intermittent intravenous doses). Systemic opioid regimen was not standardized.
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Elkassabany et al

J Orthop Trauma  Volume 29, Number 9, September 2015

Orthopedic surgery residents are instructed to prescribe IV

PCA to patients whose pain is not well controlled despite
the oral regimen. Patients in the regional group were prescribed IV PCA less frequently than those in the no-regional
group (P = 0.03).
Patients in the regional group reported signicantly
lower worst pain scores over a 24-hour period despite of the
fact that the survey questions were administered after the
PNB effect resolved. This observation was not consistent with
the results of a previous study by Goldstein et al, which
concluded that the analgesic benets of popliteal blocks in
ankle fracture lasted only until 12 hours after surgery and was
followed by worse pain scores in the PNB group. Their
ndings were attributed in part to the phenomenon of rebound
pain in the PNB group.22 The use of multimodal analgesia in
our study may have decreased the effect of rebound pain
phenomenon on the worst pain score experienced in the
regional group.
Patients in the regional group scored better when asked
about their perception of the amount of information received
about their postoperative pain management options and their
participation in the decision making. This may be because the
anesthesia providers spend more time going over the details
of the nerve blocks and alternative strategies for postoperative
analgesia during the informed consent process if a nerve
block is not performed.
Few other studies addressed other benets of regional
PNBs in foot and ankle fractures. Hunt et al23 showed that the
use of continuous nerve blocks in an ambulatory setting resulted in lower hospital costs and better analgesia after xation of calcaneal fractures. Our results have shown shorter
hospital length of stay in the regional group, which may translate into hospital cost savings.
In this prospective series, administration of PNBs,
overall pain relief, receiving more information about options
for analgesia, and participation in the decision making
regarding options for postoperative analgesia were positively correlated with satisfaction scores. Although there is
an increasing emphasis on patient empowerment and shared
decision making, evidence suggests that age, socioeconomic
status, illness experience, and the gravity of the decision
may inuence the patient desire to be part of the decisionmaking process.24 Shared decision making predicted higher
patient satisfaction with their care in medical and surgical
settings.25,26
In this study, satisfaction with postoperative pain
management was not different between patients with chronic
pain and those who did not have it. Patient satisfaction with
RA has been investigated before in multiple studies, most
often as a secondary end point.27 Patients who received RA
had higher satisfaction scores when compared with those who
received systemic analgesia or placebo.2730 Predictors of
patient satisfaction include patient-related and providerrelated variables.31,32 Female gender and increase in age have
been correlated, in other studies, with higher level of satisfaction. Patientprovider interaction is an important determinant of satisfaction.31
This study has several limitations. First, the heterogeneous nature of the fracture types and possibly the

mechanisms of injury may result in different pain trajectory

for each fracture. We presented fractures below the knee
(tibia and ankle fractures) in an attempt to have comparable
injury patterns. Fractures below the knee were also amenable to a standardized PNB protocol (popliteal sciatic nerve
block and saphenous nerve block). Second, the potential for
selection bias as to which patients are offered PNBs.
Administration of the PNB in the orthopedic trauma
operating rooms in our institution depends mainly on the
availability of a staff anesthesiologist with expertise in RA.
This may attenuate the effect of selection bias on our
results. As the study is not randomized, the potential for
unknown confounders that may inuence the results may
exist. Third, short-term follow-up for only 48 hours and the
fact that we did not collect data about functional outcome or
long-term use of opioids at home limited our ability to make
any conclusion about the long-term benets of RA in
orthopedic trauma. Finally, opioid management during
and after surgery was not standardized and was left to the
discretion of the anesthesia team and to the orthopedic
house staff, respectively, which may have affected pain
scores during different time intervals. However, the focus of
this study is how much RA improves the overall quality of
postoperative analgesia and recovery.
In conclusion, PNBs after surgery for injuries below the
knee improved the quality of pain management and increased
patient satisfaction scores compared with those patients
receiving only systemic analgesia within the rst 24 hours
after surgery. This study highlights the importance of
measurement of patient-centered outcomes in assessment of
the benets of RA.

408

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ACKNOWLEDGMENTS
The authors would like to thank Edward R. Mariano,
MD, MAS (clinical research), Associate Professor of Anesthesiology at Stanford University School of Medicine, and
Chief of Anesthesiology and Perioperative Care Service at
the Palo Alto Veterans Affairs Health System, for his review
and edits to the article.
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