The choice between general anesthesia and neuraxial techniques (spinal or epidural block) for total hip replacement has evolved substantially as surgical techniques and the practice of anesthesia have advanced. Early meta-analyses framed neuraxial anesthesia as the favorable approach across nearly every measured outcome, while a more recent randomized and population-level data have introduced important nuance, particularly as fast-track surgical protocols and modern anesthetic agents have changed practice patterns.
Mauermann, Shilling, and Zuo (2006) pooled data from ten independent trials compromising 33 patients under general anesthesia and 348 under neuraxial block. Their analysis found that neuraxial anesthesia reduced operative time by 7.1 minutes per case and intraoperative blood loss by 275 mL per case, while also lowering the odds of deep venous thrombosis (DVT) and pulmonary embolism (PE) substantially compared with GA. Fewer patients in the neuraxial group requires blood transfusion, through confidence intervals for this outcome were wide. The authors cautioned, however, that most contributing studies predated routine pharmacologic thromboprophylaxis, limiting direct applicability to contemporary practice.
A later meta-analysis included 21 randomized trials covering both total hip and total knee replacement (Hu et al., 2009). Analysis found that neuraxial anesthesia reduced operating time, transfusion requirements, and thromboembolic disease incidence in total hip replacement compared to general anesthesia. However, subgroup analysis revealed that the protective effect against DVT and PE disappeared once thromboembolic disease prophylaxis was administered, suggesting that much of the earlier-observed benefit reflected the absence of modern anti-coagulation rather than an independent effect of anesthetic technique. The authors also found that excluding trials confounded by intentional hypotension eliminated the apparent blood-loss advantage of neuraxial anesthesia.
Research from a 2015 study that analyzed over 20,000 total hip patients in the American College of Surgeons National Surgical Quality Improvement Program database found that general anesthesia was associated with increased odds of any adverse event, prolonged ventilator use, unplanned intubation, stroke, cardiac arrest, and blood transfusion, even after propensity-score adjustment for comorbidity burden (Basques et al., 2015). These associations persisted across