Psychological Factors, Not Opioid Use, Linked with Disability After Fracture Surgery

Ankle surgery
Ankle surgery
Post-operative opioid therapy may not be necessary for patients undergoing ankle surgery.

According to a study published in the Journal of the American Academy of Orthopedic Surgeons, postoperative opioid therapy may not be necessary for patients undergoing ankle surgery.1

Opioid analgesics are prescribed after surgery for US patients at much higher rates than for patients in other countries, although studies have shown pain relief and treatment satisfaction to be inferior in patients with high vs low opioid intake after fracture surgery.2-4 “These findings call the opioid-centric pain management model into question,” emphasized the authors of the current study.

They investigated associations between opioid consumption, symptom intensity, and disability level in 59 adult patients (52% women) who underwent open reduction and internal fixation of an ankle fracture at a level I trauma center. The researchers examined these associations at the time of suture removal and 5 to 8 months later. In addition, they explored factors thought to be independently linked with measures of pain and treatment satisfaction. 

Patient assessments included the Foot and Ankle Ability Measure, the Pain Anxiety Symptoms Scale, short version; the Pain Catastrophizing Scale; the Patient Health Questionnaire-2; and 11-point numeric rating scales to measure pain with activity and at rest, as well as satisfaction with pain management and overall treatment.

At 5 to 8 months after suture removal, 24% of patients were still using opioids. Opioid use was not found to be associated with disability, pain management satisfaction, or treatment satisfaction. Specific findings were as follows:

At the time of suture removal, decreased disability was independently associated with less catastrophic thinking (β = –1.2; 95% CI, –1.7 to –0.72; P <.001; semipartial R2 = 0.20 — this parameter reflects how much each variable accounts for the observed variability), and with being married and having sports injuries.

  • At the 5 to 8 month follow-up time point, an independent association was observed between decreased disability and lower pain anxiety at suture removal (β = –1.1; 95% CI, –1.7 to –0.48; P =.001; semipartial R2 = 0.19).
  • At suture removal, an independent association was found between greater treatment satisfaction and less catastrophic thinking (β = –0.088; 95% CI, –0.12 to –0.053; P <.001; semipartial R2 = 0.21).
  • Reduced catastrophic thinking was independently associated with greater satisfaction with pain management at suture removal (β = –0.11; 95% CI, –0.15 to –0.063; P <.001; semipartial R2 = 0.19) and at the 5 to 8 months time point (β = –0.10; 95% CI, –0.18 to –0.028; P =.007; semipartial R2 = 0.1)
  • Elevated pain at rest was independently associated with an increase in catastrophic thinking (β = 0.15; 95% CI, 0.11–0.20; P <.001; semipartial R2 = 0.32) and higher opioid intake (β = 0.042; 95% CI,0.021–0.063; P <.001; semipartial R2 = 0.14) at suture removal
  • Greater pain with activity was associated with increased catastrophic thinking (β = 0.16; 95% CI, 0.11–0.21; P <.001; semipartial R2 = 0.27) and higher opioid intake (β = 0.048; 95% CI, 0.024–0.072; P <.001; semipartial R2 = 0.14) at suture removal. At the 5 to 8 month follow-up, an independent association between greater pain with activity and greater catastrophic thinking at suture removal was still present (β = 0.15; 95% CI, 0.060–0.24; P =.001; semipartial R2 = 0.17).

“Our results affirm efforts to move away from the opioid-centric model of pain management and proactively address stress, distress, and ineffective coping strategies….in addition to the use of analgesics, elevation, ice, and other physical strategies,” the authors concluded.

Limitations and Disclosures

The calculation of oral morphine equivalents (OMEs) from patient-reported medications and dosages may have presented recall bias, and the assessment of FAAM at the time of suture removal may not have allowed sufficient time for patients to attempt some items on the questionnaire.

Several of the authors listed potential conflicts within the article.


Psychological variables, particularly catastrophic thinking, were found to be consistently associated with disability and measures of pain and treatment satisfaction following surgery for ankle fracture.


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  1. Finger A, Teunis T, Hageman MG, Ziady ER, Ring D, Heng M. Association between opioid intake and disability after surgical management of ankle fractures. J Am Acad Orthop Surg2017;25(7):519-526. doi:10.5435/JAAOS-D-16-00505 28574942
  1. Lindenhovius AL, Helmerhorst GT, Schnellen AC, Vrahas M, Ring D, Kloen P. Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands. J Trauma. 2009;67(1):160-164. doi:10.1097/TA.0b013e31818c12ee
  2. Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014;472(8):2542-2549. doi:10.1007/s11999-014-3660-4
  3. Helmerhorst GT, Vranceanu AM, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014;96(6):495-499. doi:10.2106/JBJS.L.01406