In Brief | Critical Care, Anaesthesia & Emergency Medicine | Gerontology
The Impact of Anaesthetic Choice on Long-Term Outcomes in Hip and Knee Arthroplasty
Time to read: 03:47
Time to listen: 07:45
Originally Published: August 2024
Sourced: Anesthesia
Type of article: In Brief
MedED Catalogue Reference: MCCIB0016
Category: Anaesthetics
Cross Reference: Surgery, Anaesthetics
Keywords: general anaesthesia, regional anaesthesia, arthroplasty, lower limb arthroplasty, mortality, morbitidy, depression
Both GA and RA are viable options for hip and knee arthroplasty with similar one-year mortality rates. However, their impact on long-term outcomes, including depression, highlights the need for a more considered approach to anaesthesia choice.
This article is a review of recent studies originally published in the Anaesthesia, 12 December 2024. This article does not represent the original research, nor is it intended to replace the original research. Access the full Disclaimer Information.
The debate over the choice between general anaesthesia (GA) and regional anaesthesia (RA) for hip and knee arthroplasty continues, particularly regarding their effects on long-term patient outcomes.
In recent years, preferences have shifted towards RA, particularly in older patients, as studies suggest it may improve perioperative outcomes.2 A key study by Fields et al, found that patients undergoing hip fracture repair under GA had a higher risk of 30-day complications compared to those receiving spinal anaesthesia, lending weight to recommendations for the use of RA in hip arthroplasty.1
To date, research has focused primarily on short-term postoperative outcomes, but the influence of anaesthetic techniques on long-term clinical outcomes and healthcare utilisation remains less clearly defined. Addressing this knowledge gap, researchers published a study in Anesthesia (December 2024), providing new insights into how GA and RA impact patients beyond the immediate perioperative period.
Study Purpose
The study aimed to compare one-year clinical outcomes and healthcare utilisation among patients undergoing hip or knee arthroplasty with either GA or RA.
The primary outcome was all-cause mortality one year post-surgery.
Secondary outcomes included the incidence of dementia, cerebral infarction, pneumonia, major depression, care provider dependency, and hospital readmission rates within the same timeframe.
Study Methodology
The researchers conducted a retrospective analysis of 247,142 patients aged 40 to 90 years who underwent hip or knee arthroplasty between 2010 and 2023.
To minimise confounding variables, propensity score matching was employed, resulting in two well-balanced cohorts of 12,558 patients each for GA and RA.
Additionally, subgroup analyses were performed to evaluate differences based on sex, age (40–70 years vs. >70 years), and surgical timeframe (2010–2016 vs. 2017–2023) to account for evolving perioperative practices and patient characteristics.
Findings
The findings revealed no significant difference in one-year all-cause mortality between GA and RA (HR 1.12, 95% CI 0.89–1.41, p=0.322).
However, beyond survival, the data presented a more nuanced picture.
Patients who received GA had a lower incidence of major depression (HR 0.82, 95% CI 0.70–0.97, p=0.021) and were significantly less likely to require long-term care provider support postoperatively (HR 0.47, 95% CI 0.38–0.58, p<0.001).
These findings challenge the conventional assumption that RA, by mitigating perioperative systemic effects, necessarily leads to better long-term functional independence.
However, this benefit came at a cost. Patients in the GA cohort exhibited a higher likelihood of hospital readmission within a year (HR 1.22, 95% CI 1.16–1.29, p<0.001), raising important questions about the underlying reasons for this increased readmission risk.
Subgroup analyses suggested that the impact of anaesthetic choice may not be uniform across all patient groups.
Factors such as age, sex, and perioperative care advancements over time appeared to play a role in modulating outcomes, highlighting the complexity of anaesthetic decision-making.
Discussion
For anaesthetists, this study reinforces the importance of balancing short-term advantages against potential long-term trade-offs when selecting an anaesthetic approach for arthroplasty procedures.
While GA and RA demonstrate comparable one-year mortality rates, their differential effects on other long-term outcomes underscore the need for a patient-centred approach.
Crucially, the association of GA with lower rates of major depression and care provider dependency, despite an increased readmission risk, highlights the interplay between anaesthetic choice and postoperative psychological and functional recovery. Given that major depressive disorder is a known complication of surgery, with potential implications for morbidity and mortality, the observed reduction in depression with GA warrants further investigation.
Conclusion
Ultimately, these findings suggest that anaesthetic choice should not be based solely on perioperative risks but should also account for long-term patient well-being. A nuanced, individualised approach—incorporating patient-specific risk factors and evolving perioperative strategies—may help optimise both immediate surgical success and extended postoperative recovery.
Importance of this study for South Africa
A substantial number of hip replacement procedures are performed across South Africa, with estimates ranging between 300 and 400 surgeries each month.3
These procedures come at a considerable financial cost, ranging from R80,000 to R150,000 per case, depending on the hospital setting and length of stay. Given this significant investment—both in terms of healthcare resources and patient outcomes—it is crucial to adopt an approach that prioritises optimised perioperative care and long-term recovery.
Reducing postoperative mortality and minimising hospital length of stay could substantially ease the disease burden associated with these procedures, improving both patient well-being and healthcare system efficiency.
While the findings of this study do not provide definitive conclusions, they offer valuable insights that can support clinical decision-making and contribute to ongoing discussions around best practices in hip replacement surgery.
Additional References
1. Fields, Adam C. et al. Short-term complications in hip fracture surgery using spinal versus general anaesthesia, Injury, Volume 46, Issue 4, 719 - 723
2. Ghoneim MM, O'Hara MW. Depression and postoperative complications: an overview. BMC Surg. 2016 Feb 2;16:5. doi: 10.1186/s12893-016-0120-y. PMID: 26830195; PMCID: PMC4736276
3. Plenge, U., Parker, R., Davids, S. et al. Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study. BMC Musculoskelet Disord 21, 721 (2020). https://doi.org/10.1186/s12891-020-03752-x
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