Ankle arthroscopy is increasingly performed as a day-case procedure, making rapid recovery and efficient discharge critical. Anesthetic technique substantially influences postoperative recovery, yet high-quality evidence comparing anesthetic strategies in ankle arthroscopy is limited.

This multicenter randomized trial compares total intravenous anesthesia with propofol plus peripheral nerve block (PNB), general anesthesia plus PNB, and spinal anesthesia, with PACU-I recovery time as the primary outcome. Secondary outcomes include postoperative pain, opioid consumption, hospital length of stay, adverse events, recovery quality, satisfaction, limb weakness, and intraoperative hemodynamics.

Ankle injuries account for 15%-25% of all sports-related injuries, consistently ranking among the most common conditions encountered in sports medicine. Ankle arthroscopy, as a minimally invasive surgical technique, has become the preferred treatment modality. Today, most ankle arthroscopies are performed on a day-case or outpatient basis, where minimizing hospital length of stay is a shared goal between patients and healthcare systems.

Anesthesia, a critical component of surgical care, directly affects patient turnover and discharge efficiency. Total intravenous anesthesia with propofol (TIVA-P) has emerged as an optimized anesthetic approach, offering rapid onset and recovery, as well as reduced incidence of postoperative nausea and vomiting. While previous studies have shown that TIVA-P can significantly shorten Phase I post-anesthesia care unit (PACU-I) time, high-level clinical evidence in ankle arthroscopy is lacking. Therefore, further investigation is warranted to evaluate its potential role in improving surgical efficiency and accelerating recovery in this setting.

The aim of this study is to compare TIVA-P combined with peripheral nerve block (PNB) versus general anesthesia (GA) with PNB and spinal anesthesia in terms of PACU-I recovery time, and to determine whether clinically meaningful differences exist.

Secondary outcomes include:

Area under the curve (AUC) of the NRS pain scores within 24 hours postoperatively (at 2, 6, 12, 18, and 24 hours);

Total oxycodone/acetaminophen consumption within 24 hours postoperatively, converted to oral morphine equivalents (OME);

Total length of hospital stay, defined as time from operating room entry to discharge;

Duration of stay in PACU-II;

Incidence of postoperative adverse events (nausea, vomiting, headache, urinary retention);

QoR-15 (Quality of Recovery-15) scores;

Satisfaction ratings from patients, surgeons, and anesthesiologists (4-point Likert scale);

Patient-reported limb weakness using a 0-10 NRS scale;

Intraoperative hemodynamics, including incidence of hypotension or hypertension and the use of vasoactive medications.

Inclusion Criteria:

• Full understanding of the study procedures and methods, with a signed written informed consent form.
• Aged 18 to 65 years, of either sex.
• Scheduled for elective unilateral minimally invasive ankle surgery.
• American Society of Anesthesiologists (ASA) physical status classification I or II.
• Body Mass Index (BMI) between 16 and 32 kg/m^2

Exclusion Criteria:

• Known hypersensitivity or allergy to any study medications or existing contraindications to anesthesia.
• Chronic obstructive pulmonary disease (COPD) or unstable asthma.
• History of difficult airway management, poorly controlled gastroesophageal reflux disease (GERD), or a known risk of aspiration.
• Anticipated surgical duration exceeding 3 hours.
• History of chronic preoperative opioid use or dependence.
• History of severe postoperative adverse reactions (e.g., severe postoperative nausea and vomiting).
• Pregnancy or lactation.
• History of seizure disorders or epilepsy.
• Severe peripheral neuropathy.
• Any other condition that, in the opinion of the investigator, would preclude safe participation in the study.

Owing to the nature of the anesthetic interventions, anesthesiologists were not blinded to group allocation. However, all postoperative outcome assessors, PACU personnel responsible for recovery assessment, follow-up investigators, and data analysts were blinded to treatment assignment.

Randomization was performed by an independent investigator, and group allocation was concealed from investigators involved in postoperative care and outcome assessment throughout the study period.