Each year, more than 300,000 hip fractures occur in the United States [1]. In 2012, a study reported that 5% of hip surgery patients die during hospitalization and 10% within 30 days of hip surgery due to cardiovascular and pulmonary complications [2]. For decades, general anesthesia was the anesthesia method of choice for major hip surgeries [3]. However, recent studies indicate that regional anesthesia may lead to better outcomes than general anesthesia [3]. Consequently, it is worth comparing general anesthesia to regional anesthesia to determine whether clinicians should use regional anesthesia during hip surgery.

Currently, it is difficult to say whether regional anesthesia leads to lower patient mortality than general anesthesia. Multiple studies have examined this question and found varying results. In 2012, Neuman et al. retrospectively analyzed the cases of 18,158 patients who received major hip surgery [2]. The researchers found that regional anesthesia patients experienced 29% lower odds of mortality than general anesthesia patients [2]. The lowered rate of mortality was especially pronounced in patients suffering from intertrochanteric fractures; this was not the case for patients who experienced femoral neck fractures [2]. Elderly mortality rates also seem to diminish when hip surgery patients receive regional anesthesia, as indicated by an analysis of 7,585 patients, though only marginally [4].

Despite those promising observations, other compelling analyses have yielded different results. A 2014 study conducted by Neuman et al. analyzed the cases of 56,729 patients, all age 50 or older, in New York [1]. The 30-day mortality of regional anesthesia patients was not significantly lower than that of general anesthesia patients [1]. Smaller studies also corroborate these findings [5]. In response to the contradictory findings of past studies, Neuman et al. suggested that many previous researchers did not adjust for potentially important confounders [1]. That same study admits to limitations itself, in terms of geographic homogeneity and missing anesthesia-related data, so it is clear that this matter requires further investigation [1].

However uncertain the mortality-based advantages of regional anesthesia, one of its better-corroborated benefits is a reduction of postoperative complications. Regional anesthesia has been found to result in lower blood loss and a reduced risk of deep venous thrombosis for hip surgery patients [3]. Additionally, the technique appears to reduce patients’ risk of thromboembolism by as much as 50% compared to general anesthesia [3]. Neuman et al. found the rate of pulmonary complications to be 24% lower in patients who received regional anesthesia [2]. Regional anesthesia can also lead patients to consume fewer opioids, undergo rehabilitation earlier, and express greater postoperative satisfaction [3].

Regardless, some findings may give clinicians pause before choosing regional anesthesia over general anesthesia. For one, a study found that elderly hip surgery patients receiving regional anesthesia experienced greater rates of delirium than those who received general anesthesia [6]. The 2014 Neuman et al. study found that hospital stays were only lowered by 0.6 days when hip surgery patients received regional anesthesia [1]. Furthermore, a study of about 1,084 hip surgery patients found no significant difference in deep venous thrombosis occurrences or length of hospital stay between cohorts, but it did confirm the significant reduction in blood loss caused by regional anesthesia [5].

Whether clinicians should uniformly prefer general or regional anesthesia when conducting major hip surgery remains unclear. However, knowing that regional and general anesthesia can impact patients differently according to various factors is important when choosing the ideal anesthetic for each patient.

References 

[1] M. D. Neuman et al., “Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery,“ JAMA, vol. 311, no. 24, p. 2508-2517, June 2014. [Online]. Available: https://doi.org/10.1001/jama.2014.6499. 

[2] M. D. Neuman et al., “Comparative Effectiveness of Regional versus General Anesthesia for Hip Fracture Surgery in Adults,” Anesthesiology, vol. 117, p. 72-92, July 2012. [Online]. Available: https://doi.org/10.1097/ALN.0b013e3182545e7c. 

[3] P. F. Indelli et al., “Regional Anesthesia in Hip Surgery,“ Clinical Orthopaedics and Related Research, vol. 441, p. 250-255, December 2005. [Online]. Available: https://doi.org/10.1097/01.blo.0000192355.71966.8e. 

[4] W. T. Brox et al., “Similar mortality with general or regional anesthesia in elderly hip fracture patients,” Acta Orthopaedica, vol. 87, no. 2, p. 152-157, January 2016. [Online]. Available: https://doi.org/10.3109/17453674.2015.1128781. 

[5] X. Zheng et al., “Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials,“ BMC Anesthesiology, vol. 20, no. 162, p. 1-12, June 2020. [Online]. Available: https://doi.org/10.1186/s12871-020-01074-y. 

[6] C. J. Slor et al., “Anesthesia and Postoperative Delirium in Older Adults Undergoing Hip Surgery,” Journal of the American Geriatrics Society, vol. 59, no. 7, p. 1313-1319, June 2011. [Online]. Available: https://doi.org/10.1111/j.1532-5415.2011.03452.x.