Only the lonely: A risk factor we can influence

In my waning career, I am more proud of the hands I held than the bones I healed.

Maturing as surgeons brings the realization that we do not operate on bones, we operate on people. You can execute a perfect open reduction and internal fixation for a femoral neck fracture, follow best practices to steer your patient through the postop medical complication gauntlet, but if the patient fails to thrive, the surgery is not a success. Your time with patients and family is limited, but one of your precious minutes could improve the outcome for a lonely patient.

After the U.S. surgeon general declared an epidemic of loneliness in 2023, studies flooded the popular and medical press. Loneliness and social isolation are distinct: social isolation is the objective decrease in social connections, whereas loneliness is the subjective experience of inadequate connections. Well-done studies distinguish between these; for the surgical team, one can be a marker for the other.

How does loneliness impact health?

The psychological aspects of social isolation and loneliness impact both biology and behavior. As with other social stressors, evidence has demonstrated the physiologic influences of loneliness through neuroendocrine stress activation, increasing inflammation and altering immune function. Affected behaviors include decreased physical activity, poor nutrition and sleep, and difficulty with treatment adherence. This manifests in increased risks of heart disease, stroke, and premature death. In the musculoskeletal system, researchers demonstrated an association between increased loneliness scores and increased presence of osteoporosis and osteopenia. Longitudinally, these patients also showed greater sarcopenia based on a multi-question scale. Combining these health impacts with a prevalence of over half of U.S. adults reporting loneliness informed the callout of a loneliness epidemic.

Loneliness, social isolation, and surgical outcomes

A recent study published in JAMA noted the impact of loneliness on surgical recovery, demonstrating that self-report loneliness was associated with an increased 30-day postop mortality for non-elective surgery. Although that study did not assess orthopaedic procedures, a recent prospective study in the Journal of Orthopaedic Trauma focused on the impact of social isolation on hip fracture patients. Questionnaires were used to assess both social isolation and loneliness, and the Lower Extremity Activity Scale and PROMIS-29 followed functional outcomes. A third of patients were considered socially isolated at baseline, and these patients had worse PROMIS-29 scores at one year post surgery. Similarly, baseline loneliness impacted one-year function, including emotional status. From various studies, social isolation appears more consistently associated with adverse physical outcomes, while loneliness shows stronger associations with patient-reported outcomes and psychological well-being.

The anesthesia literature has assessed the impact of social determinants, including loneliness, on chronic pain.Evaluating more than 8,000 surgical cases, Mehdipour and colleagues found an association between increased loneliness and persistent pain. In a subgroup of 496 total joint arthroplasty patients, food insecurity was found to have a significant association with prolonged pain. However, while the odds ratio for persistent pain developing in the setting of loneliness was 1.05, statistical significance was not reached for the subgroup. A study using a United Kingdom database demonstrated increased odds of postop complications for socially isolated patients (males greater than females). From this study, social isolation appeared to be a more important factor than loneliness.

Helping your patients

Screening, even a single question, “Who will be helping you after surgery?” can be an assessment and start the conversation.

For elective cases, assess the social readiness of the patient and the existing support network before surgery. As more health systems move toward team-based, preemptive care pathways such as Enhanced Recovery After Surgery (ERAS), resources may exist to direct patients to community resources. Social workers or case managers can identify resources, including meal or transportation programs. A study in the nursing literature from Sweden found that a postop phone call was reassuring for patients. Technology could offer more options, including telehealth or remote monitoring.

While it can be staff-led, surgeons should not forget that patients often imbue our words with much greater importance. Not all our patients will have people to whom they can turn, but sometimes people are simply reluctant to ask for help. When discussing the recovery with your patient, emphasize that postop recovery is the time to ask for help from friends, family, church, or community. Certainly, engage any caregivers who may be in the exam room as potential partners in the patient’s recovery.

Even in the absence of screening, recognize high-risk groups, including the elderly and patients living alone. We know the hip fracture patients face overwhelming postoperative risks; this is a population where any intervention can have the most impact.

In trauma or non-elective cases, the surgeon’s word can be even more powerful. Use your brief connection to family or friends in the emergency department and during your post-surgery call as an opportunity to engage their assistance. These people may not remember any surgical details you share, but they will likely understand “Being there for Mrs. Smith in these next weeks as she recovers can make all the difference.”

Conquering loneliness is not easy, but enhancing support in the brief, critical postop window may be achievable for many patients. There are many ways a technically perfect surgery can be undermined, not all of them modifiable. Yet only a word from you, the surgeon, could help your lonely patient.

Alexandra E. Page, MD, FAAOS, is a foot and ankle specialist in private practice in San Diego, California, and the editor-in-chief of AAOS Now.

References

1. Office of the U.S. Surgeon General. Our epidemic of loneliness and isolation: the U.S. Surgeon General’s advisory on the healing effects of social connection and community. U.S. Department of Health and Human Services; 2023. Accessed June 2, 2026.https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf
2. Shen MR, Suwanabol PA, Howard RA, et al. Association between loneliness and postoperative mortality among Medicare beneficiaries. JAMA Surg. 2023;158(2):212-214. doi:10.1001/jamasurg.2022.4784
3. Mandl LA, Rajan M, Lipschultz RA, Lian S, Sheira DB, Frey MB, et al. The effect of social isolation on 1-year outcomes after surgical repair of low-energy hip fracture. J Orthop Trauma. 2024;38(4):e149-e156. doi:10.1097/BOT.0000000000002772
4. Mehdipour S, Rodriguez L, Gabriel RA. A multi-institutional and nationwide analysis of the social determinants of persistent pain after surgery. Anesth Analg. 2026;142(6):1198-1205. doi:10.1213/ANE.0000000000007807
5. Xu Z, Li Y, Song H, Sit RWS, Leung JCS, Chan DCC, et al. The association of loneliness with bone mineral density, osteoporosis, osteopenia, fall, and sarcopenia among older adults: results from Mr. and Ms. Os (Hong Kong) study. Osteoporos Int. 2025;36(12):2471-2481. doi:10.1007/s00198-025-07720-w
6. Larsson F, Strömbäck U, Gustafsson SR, Engström Å. Postoperative recovery: experiences of patients who have undergone orthopedic day surgery. J Perianesth Nurs. 2022;37(4):515-520. doi:10.1016/j.jopan.2021.10.012
7. Philip K, Jolly A, Diep C, et al. Association of loneliness and social isolation with postoperative outcomes: a retrospective registry study. Br J Anaesth. 2026 Jan;136(1):247-254. doi:10.1016/j.bja.2025.09.004. Epub 2025 Oct 23. PMID: 41136321; PMCID: PMC12851873.