Factors Influencing Postoperative Recovery after Lower Extremity Surgery: A Prospective Cohort Study

Amornrat Sangsaikaew; Apinya Koontalay; Khunphitha Junsevg; Arunrat Utaisang

doi:10.14710/nmjn.v16i2.80772

DOI: https://doi.org/10.14710/nmjn.v16i2.80772

Factors Influencing Postoperative Recovery after Lower Extremity Surgery: A Prospective Cohort Study

*Amornrat Sangsaikaew - Department of Adult and Aging Nursing, Boromarajonani College of Nursing Nakhon Phanom, Nakhon Phanom University, Thailand

Apinya Koontalay - Australia, Australia

Khunphitha Junsevg - Department of Adult and Aging Nursing, Boromarajonani College of Nursing Nakhon Phanom, Nakhon Phanom University, Thailand

Arunrat Utaisang - Department of Adult and Aging Nursing, Boromarajonani College of Nursing Nakhon Phanom, Nakhon Phanom University, Thailand

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

BibTex Citation Data :

@article{NMJN80772,
    author = {Amornrat Sangsaikaew and Apinya Koontalay and Khunphitha Junsevg and Arunrat Utaisang},
    title = {Factors Influencing Postoperative Recovery after Lower Extremity Surgery: A Prospective Cohort Study},
    journal = {Nurse Media Journal of Nursing},
  volume = {16},
    number = {2},
    year = {2026},
    keywords = {Cohort study; health-related quality of life; lower extremity surgery; postoperative recovery; self-efficacy},
    abstract = {  Background:  Suboptimal health-related quality of life (HRQoL) during recovery from lower-extremity surgery can increase healthcare costs and reduce patients’ overall well-being. However, evidence regarding factors influencing HRQoL trajectories remains limited.   Purpose:  This study examined predictors of HRQoL and self-efficacy at weeks 1 and 4 after hospital discharge in patients undergoing lower-extremity orthopedic surgery.   Methods:  This prospective cohort study used consecutive sampling to recruit 90 patients undergoing lower-extremity orthopedic surgery (hip, femur, knee, tibia) at a tertiary hospital in Thailand. Collected data included demographic characteristics, clinical factors, anthropometric measurements (body mass index [BMI] and waist circumference), and surgical variables. Outcomes were assessed at weeks 1 and 4 after discharge using the 12-Item Short Form Health Survey (SF-12) to measure HRQoL and a validated 25-item questionnaire to measure self-efficacy. Multiple regression analysis was used to identify independent predictors of postoperative HRQoL, while paired-samples t-tests were used to examine changes in HRQoL and self-efficacy between weeks 1 and 4.   Results:  This study found that BMI independently predicted poorer physical-domain HRQoL at week 1 (β = -0.54,  p  = 0.023) and week 4 (β = -0.62,  p  = 0.008). Waist circumference emerged as an additional predictor of the physical domain of HRQoL at week 4 (β = -0.58,  p  = 0.002). The regression models explained 22.8% of the variance at week 1 (R² = 0.228,  p  < 0.001) and 21.8% at week 4 (R² = 0.218,  p  < 0.001). Self-efficacy improved substantially from week 1 to week 4 (MD = 14.33, SDD = 9.86, Cohen’s d = 2.03,  p  < 0.001). In contrast, the SF-12 physical component summary (PCS) scores remained unchanged (week 1: M = 28.21, SD = 1.66; week 4: M = 28.11, SD = 1.30; MD = -0.10, SDD = 1.35, Cohen’s d = 0.07,  p  = 0.571), revealing a marked dissociation between improved psychological confidence and stable outcomes in the physical domain of HRQoL.  Conclusion:  Elevated BMI consistently predicts poorer postoperative HRQoL following lower extremity surgery, with improvements in the physical domain of HRQoL often lagging behind improvements in patients’ self-efficacy. Perioperative nurses should emphasize routine BMI assessment and targeted weight-management education to bridge the gap between perceived self-efficacy and physical HRQoL outcomes in perioperative care protocols.},
   issn = {2406-8799},   pages = {347--358}  doi = {10.14710/nmjn.v16i2.80772},
    url = {https://ejournal.undip.ac.id/index.php/medianers/article/view/80772}
}

Citation Format:

Abstract

Background: Suboptimal health-related quality of life (HRQoL) during recovery from lower-extremity surgery can increase healthcare costs and reduce patients’ overall well-being. However, evidence regarding factors influencing HRQoL trajectories remains limited.

Purpose: This study examined predictors of HRQoL and self-efficacy at weeks 1 and 4 after hospital discharge in patients undergoing lower-extremity orthopedic surgery.

Methods: This prospective cohort study used consecutive sampling to recruit 90 patients undergoing lower-extremity orthopedic surgery (hip, femur, knee, tibia) at a tertiary hospital in Thailand. Collected data included demographic characteristics, clinical factors, anthropometric measurements (body mass index [BMI] and waist circumference), and surgical variables. Outcomes were assessed at weeks 1 and 4 after discharge using the 12-Item Short Form Health Survey (SF-12) to measure HRQoL and a validated 25-item questionnaire to measure self-efficacy. Multiple regression analysis was used to identify independent predictors of postoperative HRQoL, while paired-samples t-tests were used to examine changes in HRQoL and self-efficacy between weeks 1 and 4.

Results: This study found that BMI independently predicted poorer physical-domain HRQoL at week 1 (β = -0.54, p = 0.023) and week 4 (β = -0.62, p = 0.008). Waist circumference emerged as an additional predictor of the physical domain of HRQoL at week 4 (β = -0.58, p = 0.002). The regression models explained 22.8% of the variance at week 1 (R² = 0.228, p < 0.001) and 21.8% at week 4 (R² = 0.218, p < 0.001). Self-efficacy improved substantially from week 1 to week 4 (MD = 14.33, SDD = 9.86, Cohen’s d = 2.03, p < 0.001). In contrast, the SF-12 physical component summary (PCS) scores remained unchanged (week 1: M = 28.21, SD = 1.66; week 4: M = 28.11, SD = 1.30; MD = -0.10, SDD = 1.35, Cohen’s d = 0.07, p = 0.571), revealing a marked dissociation between improved psychological confidence and stable outcomes in the physical domain of HRQoL.

Conclusion: Elevated BMI consistently predicts poorer postoperative HRQoL following lower extremity surgery, with improvements in the physical domain of HRQoL often lagging behind improvements in patients’ self-efficacy. Perioperative nurses should emphasize routine BMI assessment and targeted weight-management education to bridge the gap between perceived self-efficacy and physical HRQoL outcomes in perioperative care protocols.

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Keywords: Cohort study; health-related quality of life; lower extremity surgery; postoperative recovery; self-efficacy

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Language : EN

In Vol 16, No 2 (2026): (August 2026) [In Progress]

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Arnolda, J. B., Tub, C. G., & Phanc, T. M. (2017). Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review. Injury, 48(11), 2634–2642. https://doi.org/10.1016/j.injury.2017.08.043
Aprisunadi, A., Nursalam, N., Mustikasari, M., Ifadah, E., & Hapsari, E. D. (2023). Effect of early mobilization on hip and lower extremity postoperative: A literature review. SAGE Open Nursing, 9, 23779608231167825. https://doi.org/10.1177/23779608231167825
Avery, D., Morandini, L., Sheakley, L., Alajmi, A., Bergey, L., Donahue, H. J., Martin, R. K., & Olivares-Navarrete, R. (2025). Obesity prolongs the pro-inflammatory response and attenuates bone healing on titanium implants. Acta Biomaterialia, 192, 473–486. https://doi.org/10.1016/j.actbio.2024.11.040
Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman
Box, M. W., Green, A., Badylak, J., & Riehl, J. T. (2025). The influence of BMI and other measures of adiposity on risks and outcomes in orthopaedic traumatology. In Body Mass Index in Clinical Practice. IntechOpen. https://doi.org/10.5772/intechopen.1013251
Cheng, H., Clymer, W. J., Chen, P. -H. B., Sadeghirad, B., Ferko, C. N., Cameron, G. C., & Hinoul, P. (2018). Prolonged operative duration is associated with complications: A systematic review and meta-analysis. Journal of Surgical Research, 229, 134−144. https://doi.org/10.1016/j.jss.2018.03.022
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates. https://doi.org/10.4324/9780203771587
Farmus, L., Weiss, J. A., Tajik-Parvinchi, D., & Cribbie, R. A. (2020). Contextualizing statistical suppression within pretest-posttest designs. The Quantitative Methods for Psychology, 16(1), 21–32. https://doi.org/10.20982/tqmp.16.1.p021
Ferraz, S. M., Moreira, J. P., Mendes, L. C., Amaral, T. M., Andrade, A. R., Santos, A. R., Abelha, F. J., & Santos, C. L. (2019). Evaluation of quality of recovery and the postoperative health status after elective surgery. Brazilian Journal of Anesthesiology, 69(6), 577–583. https://doi.org/10.1016/j.bjan.2019.09.001
Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short‐Form McGill Pain Questionnaire (SF‐MPQ), Chronic Pain Grade Scale (CPGS), Short Form‐36 Bodily Pain Scale (SF‐36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63(S11), S120−S252. https://doi.org/10.1002/acr.20543
Karcioglu, O., Topacoglu, H., Dikme, O., & Dikme, O. (2018). A systematic review of the pain scales in adults. The American Journal of Emergency Medicine, 36(8), 1327–1337. https://doi.org/10.1016/j.ajem.2018.01.008
Lakens, D. (2013). Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs. Frontiers in Psychology, 4, 863. https://doi.org/10.3389/fpsyg.2013.00863
Master, H., Castillo, R., Wegener, T. S., Pennings, S. J., Coronado, R. A., Haug, M. C., O'Connor, D. P., & Archer, K. R. (2021). Role of psychosocial factors on the effect of physical activity on physical function in patients after lumbar spine surgery. BMC Musculoskeletal Disorders, 22(1), 883. https://doi.org/10.1186/s12891-021-04622-w
Pean, C. A., Rivero, S. M., Suneja, N., & Weaver, M. J. (2023). Severe obesity worsens 30-day surgical outcomes and projected costs in operative femoral shaft and tibial shaft fractures. Journal of Orthopaedic Trauma, 37(1), 27–31. https://doi.org/10.1097/BOT.0000000000002456
Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Wolters Kluwer Health
Rasmussen, T. E., & Koelling, E. E. (2024). Surgical management of severe lower extremity injury. UpToDate. https://www.uptodate.com/contents/surgical-management-of-severe-lower-extremity-injury
Rutherford, C., Costa, D., Mercieca-Bebber, R., Rice, H., Gabb, L., & King, M. (2016). Mode of administration does not cause bias in patient-reported outcome results: A meta-analysis. Quality of Life Research, 25(3), 559–574. https://doi.org/10.1007/s11136-015-1110-8
Schober, P., Boer, C., & Schwarte, L. A. (2018). Correlation coefficients: Appropriate use and interpretation. Anesthesia & Analgesia, 126(5), 1763–1768. https://doi.org/10.1213/ANE.000000000002864
Schwarzer, R., & Warner, L. M. (2013). Perceived self-efficacy and its relationship to resilience. In A. Prince-Embury & D. H. Saklofske (Eds.), Resilience in children, adolescents, and adults: Translating research into practice (pp. 139–150). Springer. https://doi.org/10.1007/978-1-4614-4939-3_10
Shadyab, A. H., Li, W., & LaCroix, A. Z. (2018). General and abdominal obesity as risk factors for late-life mobility limitation after total knee or hip replacement for osteoarthritis among women. Arthritis Care & Research, 70(7), 1030–1038. https://doi.org/10.1002/acr.23448
Shan, S., Shi, Q., & Zhang, H. (2024). Influencing factors on the quality of recovery after total knee arthroplasty: Development of a predictive model. Frontiers in Medicine, 11, 1427768. https://doi.org/10.3389/fmed.2024.1427768
Sousa, V. D., & Rojjanasrirat, W. (2011). Translation, adaptation and validation of instruments or scales for use in cross-cultural health research: A clear and user-friendly guideline. Journal of Evaluation in Clinical Practice, 17(2), 268–274. https://doi.org/10.1111/j.1365-2753.2010.01434.x
Tabachnick, B. G., & Fidell, L. S. (2019). Using multivariate statistics (7th ed.). Pearson
Taniguchi, M., Hiyama, Y., Kamitani, T., Kubo, M., Kawasaki, T., & Wada, O. (2020). Comparison of recovery of mobility and self-efficacy after total knee arthroplasty based on two different protocols: A prospective cohort study. Modern Rheumatology, 30(1), 197–203. https://doi.org/10.1080/14397595.2018.1553228
Tao, J., Yan, Z., Bai, G., Zhang, H., & Li, J. (2023). Enhanced recovery after surgery rehabilitation protocol in the perioperative period of orthopedics: A systematic review. Journal of Personalized Medicine, 13(3), 421. https://doi.org/10.3390/jpm13030421
Vanier, A., Oort, F. J., McClimans, L., Ow, N., Gulek, B. G., Böhnke, J. R., Sprangers, M. A. G., & the Response Shift – in Sync Working Group. (2024). Response shift results of quantitative research using patient-reported outcome measures: A descriptive systematic review. Quality of Life Research, 33(2), 293–315. https://doi.org/10.1007/s11136-023-03495-x
Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220–233. https://doi.org/10.1097/00005650-199603000-00003
Zierle-Ghosh, A., & Jan, A. (2025). Physiology, body mass index. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535456/
Zou, H., Chen, Y., Qi, X., & Wang, Y. (2024). The relationship between self-efficacy, health literacy, and quality of life in patients with chronic diseases: A cross-sectional study. Frontiers in Public Health, 12, 1430202. https://doi.org/10.3389/fpubh.2024.1430202

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Factors Influencing Postoperative Recovery after Lower Extremity Surgery: A Prospective Cohort Study

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