Preoperative Anxiety Is Associated with Early Postoperative Pain After Arthroscopic Ankle Ligament Reconstruction: A Prospective Cohort Study

Purpose: We evaluate the relationship between preoperative anxiety, as measured by the Surgical Fear Questionnaire (SFQ), and postoperative pain intensity during the first three days following arthroscopic ankle ligament reconstruction. A secondary objective was to determine whether preoperative anxiety levels are associated with failure to reach the Patient Acceptable Symptom State (PASS) threshold for pain by postoperative day 3. Methods: A prospective cohort of 68 patients undergoing anatomic arthroscopic ankle lateral ligament reconstruction between January 2023 and March 2025 was assessed. Patients were categorized into high- and low-anxiety groups based on a tertile distribution of SFQ scores, with a threshold of 45. Pain intensity was measured using the Visual Analog Scale (VAS) on days 0, 1, 2, and 3 postoperatively. The proportion of patients with unacceptable pain (VAS > 3) according to the patient’s acceptable symptom state was compared between groups. A receiver operating characteristic (ROC) curve identified the optimal SFQ threshold for discriminating PASS achievement on day 3. Odds ratios were calculated using logistic regression. Results: A total of 68 patients were included (34 in each group). The mean age was 32.9 ± 10.5 years in the high-anxiety group and 33.1 ± 9.9 years in the low-anxiety group (p = 0.747). The mean SFQ score was 58.9 ± 11.9 in the high-anxiety group and 28.0 ± 10.8 in the low-anxiety group (p < 0.001). There were no significant differences between groups in demographic characteristics. Patients in the high-anxiety group reported significantly higher VAS scores at all postoperative time points. The proportion failing to achieve PASS on day 3 was also significantly greater in the high-anxiety group (67.6% vs. 35.3%, p = 0.015). An SFQ threshold of 46 discriminated PASS status with an AUC of 0.70. Patients with SFQ ≥ 46 had more than triple the odds of not achieving PASS (OR = 3.39; 95% CI: 1.26–9.59, p = 0.017). Conclusions: Preoperative anxiety is significantly associated with early postoperative pain and pain acceptability following arthroscopic ankle ligament reconstruction. Identifying and managing high-anxiety patients preoperatively may improve pain outcomes and patient satisfaction.