Outcome of Spinal Versus General Anesthesia in Revision Total Hip Arthroplasty

A Propensity Score-Matched Cohort Analysis

Venkatsaiakhil Tirumala, MS; Georges Bounajem, MD; Christian Klemt, PhD; Stephen P. Maier, MD; Anand Padmanabha, MD; Young-Min Kwon, MD, PhD

Disclosures

J Am Acad Orthop Surg. 2021;29(13):e656-e666. 

In This Article

Abstract and Introduction

Abstract

Introduction: Spinal anesthesia has been previously shown to offer improved patient outcomes compared with general anesthesia in revision total knee arthroplasty. This study aimed to evaluate the potential differences in perioperartive and postoperative outcomes in revision total hip arthroplasty (THA) between spinal or general anesthesia.

Methods: A total of 2,656 consecutive patients who underwent revision THA were evaluated. Propensity-score-adjusted multivariate logistic regression analyses were applied to control for intergroup variability and evaluate the differences in outcomes and complications with anesthesia type.

Results: Propensity score matching resulted in 1:1 matching with 265 patients in each anesthesia cohort. Multivariate analyses demonstrated that patients administered general anesthesia had a significantly longer procedure time (174.8 versus 161.3, P < 0.01), higher intraoperative (402.6 versus 305.5 mL, P < 0.01), and total perioperative blood loss (1802.2 versus 1,684.2 mL,P < 0.01). In addition, patients administered general anesthesia were found to have higher odds for two or more inhospital complications (odds ratio, 4.51, P < 0.01) and extended length of stay (odds ratio, 2.45, P = 0.02).

Discussion: Our study shows that propensity-matched patients who received spinal anesthesia for revision THA exhibited notable reduction in surgical time, perioperative blood loss, and complications compared with patients who received general anesthesia, suggesting that spinal anesthesia is a viable alternative to general anesthesia in revision THA.

Introduction

As the volume of primary total hip arthroplasty (THA) is expected to dramatically increase in the current decade and beyond, the burden of revision surgery is expected to increase concomitantly.[1] Revision THA improves the quality of life of patients with failed implants because of various possible causes, including material wear, loosening, and instability.[2–4] However, revision THA is inherently associated with higher rates of complications than primary THA because of difficulties in managing bone loss and soft-tissue insufficiency.[5,6] One potential surgical factor associated with improved postoperative outcomes in primary total joint arthroplasty (TJA) is the use of spinal anesthesia instead of general anesthesia. Several studies have shown that when compared with general anesthesia, patients receiving spinal anesthesia during primary TJA benefit from less frequent postoperative complications such as thromboembolic events and wound infections, as well as decreased need for blood transfusions.[7,8] Proposed explanations in the literature for these reduced complication rates have included spontaneous rather than positive pressure ventilation, hypotension because of a reduction in sympathetic activation and inflammation, decrease in venous stasis, and avoidance of tracheal intubation.[9,10] Spinal anesthesia, with lower cost of anesthesia and shorter recovery periods, also confers economic benefits over general anesthesia.[11,12]

Although several studies compare the outcomes of spinal versus general anesthesia in primary THA[11,13] and total knee arthroplasty (TKA),[14] there exists a paucity of such studies in the revision TJA. In a recent retrospective study by Wilson et al,[7] the use of spinal as compared to general anesthesia was shown to be associated with decreased length of stay (LOS), readmissions, transfusions, and deep surgical site infection in the revision TKA patient, which was demonstrated using the American College of Surgeons--National Surgical Improvement (ACS-NSQIP) database. To our knowledge, no similar study exists in the literature for revision THA. Although using multi-institutional databases, such as the ACS-NSQIP, have advantages because of the large sample sizes afforded, there are a number of potential limitations in the data, including the lack of surgical history, restriction of complications to the 30-day postoperative period, and absence of subsequent re-revision surgery. This study aims to evaluate the potential impact of anesthetic type (spinal versus general) in revision THA with an analysis of both perioperative and postoperative outcomes, including 90-day complications and subsequent re-revision surgery.

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