427: Effect of Mixed Reality on Preoperative Anxiety in Orthopedic Surgery: A Randomized Trial

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Acute postsurgical pain, Psychology, Non-pharmacological treatments, Physiotherapy

Background and Aims: Preoperative anxiety affects up to 67.6% of surgical patients and is biologically linked to adverse perioperative outcomes through the anxiety-pain axis, including sleep disturbances, hyperalgesia, increased analgesic consumption, and delayed functional recovery [1,2]. Preoperative anxiety amplifies central pain sensitization and is an independent predictor of postoperative pain severity in orthopedic surgery [3]. Mixed reality (MR) technology has demonstrated potential to reduce perioperative anxiety through immersive preoperative simulation [4,5], though its downstream effects on postoperative pain remain unclear. This randomized controlled trial (RCT) evaluated whether MR-based preoperative intervention reduces severe preoperative anxiety and explored its secondary effects on postoperative pain and analgesic outcomes in patients undergoing orthopedic surgery.

Methods: This single-center RCT enrolled 300 patients (aged 18-65 years, ASA I-III) scheduled for elective orthopedic surgery . Participants were randomly assigned (1:1) to receive MR-based preoperative intervention (interactive anesthesia education, respiratory training, hand exercises, first-person anesthesia experience) or routine preoperative care (n=150 per group). The primary endpoint was the incidence of severe preoperative anxiety, defined as a State Anxiety Inventory score greater than 44 on the day of surgery [6,7]. Secondary endpoints included the Amsterdam Preoperative Anxiety and Information Scale, Richards-Campbell Sleep Questionnaire scores, postoperative State Anxiety Inventory scores, and a pain-related composite comprising visual analogue scale pain scores, patient-controlled analgesia utilization, and intraoperative sufentanil consumption. All analyses followed the intention-to-treat principle. Between-group comparisons for continuous variables were performed using Mann-Whitney U test or independent t-test; categorical variables were compared using Chi-square or Fisher's exact test. Post-hoc exploratory subgroup analyses by surgery type were performed.

Results: The intention-to-treat population comprised 300 patients (MR n=150; control n=150). Baseline characteristics were well balanced. Primary endpoint was available for 272 patients (90.7%). Severe anxiety incidence was 17.1% (24/140) versus 18.2% (24/132) (risk ratio 0.943; 95% confidence interval: 0.564-1.575; P=0.948; absolute risk difference -1.0 percentage points, 95% confidence interval: -10.1 to 8.0). For pain-related secondary endpoints, no significant differences were observed: visual analogue scale scores were 3.75+/-2.66 versus 3.81+/-2.70 (P=0.928); patient-controlled analgesia utilization was 62.4% (93/149) versus 70.9% (105/148) (P=0.151); and sufentanil consumption was 21.2+/-13.0 microg versus 19.9+/-13.3 microg (P=0.319). A post-hoc exploratory subgroup analysis found that arthroscopic surgery patients in MR group exhibited lower patient-controlled analgesia utilization versus controls (53.9% versus 66.9%; uncorrected P=0.046). Sensitivity analyses yielded consistent results.

Conclusions: In this RCT, MR-based preoperative intervention did not significantly reduce the incidence of severe preoperative anxiety compared with routine care, and no statistically significant between-group differences were observed in the prespecified secondary endpoints, including postoperative pain severity, patient-controlled analgesia utilization, or sufentanil consumption. However, the consistent directional trends across all three pain-related metrics-coupled with the exploratory observation of reduced patient-controlled analgesia use in the arthroscopic surgery subgroup (uncorrected P=0.046, not adjusted for multiple comparisons)-suggest that MR may have procedure-specific analgesic-sparing potential. These findings underscore the biological plausibility of the preoperative anxiety-postoperative pain axis and warrant adequately powered, procedure-stratified trials to test whether optimized MR protocols, particularly in minimally invasive orthopedic surgery, can achieve clinically meaningful reductions in postoperative pain and analgesic dependency. Future studies should prespecify pain-related endpoints, employ standardized multimodal analgesic pathways, and stratify by surgical invasiveness to confirm these hypothesis-generating observations.

References: [1] Tashjian RZ, Delagrammaticas DE, Bariteau JT, et al. Augmented reality for perioperative anxiety in patients undergoing surgery: a randomized clinical trial. JAMA Netw Open. 2023;6(8):e2330280.

[2] Moharam SA, Elnabtity AM, Selim EM, et al. Effect of virtual reality on perioperative anxiety, stress and pain in total hip arthroplasty: a randomized controlled trial. BMC Musculoskelet Disord. 2025;26(1):131.

[3] Kilinc O, Akyuz E. Relationship between preoperative fasting duration and anxiety levels with postoperative pain, nausea-vomiting, and sleep quality in orthopedic surgical patients: a cross-sectional study. J Perianesth Nurs. 2025;40(1):69-76.

[4] Buhari SSM, Wahab NHA, Loh YX, et al. Virtual and augmented reality for anxiety reduction in orthopedic procedures: a systematic review. Int Orthop. 2025;49(5):1123-1136.

[5] Feng H, Zhu Y, Cao J, et al. Effectiveness of nursing interventions on preoperative anxiety and postoperative outcomes among patients undergoing orthopaedic surgery: a systematic review and meta-analysis. Int J Nurs Pract. 2025;31(6):e70069.

[6] Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.

[7] Millar K, Jelicic M, Bonke B, Asbury AJ. Assessment of preoperative anxiety: comparison of two measures. Br J Cancer. 1995;71(3):695-697.

Presenting Author: Shuhan Zhuang
Submitting Author: Shuhan Zhuang

Senior Author: Tao Xu

IASP 2026 Global Year theme of Neuropathic Pain: No

• Tao Xu - Shanghai Sixth People’s Hospital