New evidence shifts hip fracture anesthesia debate
Anesthesiologists move from “which technique?” to “how is care delivered?”
After decades of debate over whether spinal or general anesthesia provides better outcomes for patients undergoing hip fracture surgery, anesthesiologists now say the focus is shifting toward a broader question: how to optimize the entire perioperative care pathway.
The evolving evidence surrounding the issue is the focus of the Saturday session, “My Anesthetic Management for Hip Fractures Surgery Is Better Than Yours: A Pro Con Debate.” Panelists will examine how two decades of research has reshaped clinical thinking about one of the most common orthopedic injuries requiring time-sensitive/urgent surgical intervention in older adults.
“Twenty years ago, neuraxial – usually spinal – anesthesia was often considered the preferable technique for hip-fracture surgery,” said Steve Coppens, MD, PhD, a Consultant of Anesthesiology at University Hospitals in Leuven, Belgium. “This was based partly on physiological reasoning and partly on observational studies suggesting lower mortality, fewer pulmonary complications, less thromboembolism, and less postoperative confusion than with general anesthesia.”
That was an appealing choice, Dr. Coppens said, because it avoided the use of airway instrumentation, volatile anesthetics, and potentially larger doses of systemic opioids that could reduce respiratory complications and postoperative “brain fog.”
However, hip-fracture patients are physiologically complex, he said, noting that delirium, postoperative cognitive impairment (perioperative neurocognitive disorders), loss of mobility, and mortality are not solely determined by the anesthetic drug or technique alone.
“They are influenced by preexisting frailty, dementia, pain, inflammation, blood loss, hypotension, hypoxemia, medications, sleep disruption, infection, surgical delay, and the quality of postoperative rehabilitation,” he said. “The effect of choosing spinal rather than general anesthesia may therefore be relatively small compared with the effect of the entire perioperative pathway.”
Several landmark clinical trials have challenged the notion that spinal anesthesia is inherently superior, Dr. Coppens said. For example, the REGAIN trial, which enrolled approximately 1,600 previously ambulatory adults with hip fractures, found that spinal anesthesia was not superior to general anesthesia for the combined outcomes of death or inability to walk independently 60 days after surgery. Rates of delirium, mortality, and longer-term functional recovery were also similar between groups. (Specifically noted in follow-up publications of the REGAIN trial.)
Likewise, Dr. Coppens said, China’s RAGA trial, involving 950 older patients, found no significant difference in postoperative delirium between regional anesthesia without sedation and general anesthesia, although the regional techniques were not limited to spinal anesthesia. Contemporary meta-analyses of randomized trials have similarly shown no convincing differences in mortality, delirium, or most patient-centered outcomes.
“Some analyses suggest possible differences in individual secondary outcomes, such as acute kidney injury or pulmonary complications, but these findings are inconsistent and generally based on relatively few events,” Dr. Coppens said. “Therefore, at present, neither general nor spinal anesthesia can be declared universally superior. Both are acceptable when they are appropriately selected and carefully administered.”
Shared decision-making
Some anesthesiologists are increasingly supporting an individualized approach rather than a one-size-fits-all recommendation. Contemporary guidance emphasizes that both spinal and general anesthesia are appropriate options when carefully selected and skillfully administered, according to session panelist Nabil M. Elkassabany, MD, a Professor of Anesthesiology at the University of Virginia School of Medicine in Charlottesville. Professional guidelines have evolved to emphasize patient characteristics, contraindications, and preferences, Dr. Elkassabany said.
“Hip fracture is an epidemiological problem with major socioeconomic impact and a resulting increase in healthcare resource utilization,” he said. “The type of anesthesia and analgesia is a modifiable variable that may result in improvement of patient outcomes.”
In cases of hip fractures, shared decision-making between the healthcare team, the patient, and his or her family is essential, said session moderator Ruth Burstrom, MD. Dr. Burstrom, a Professor of Anesthesiology at the University of New Mexico in Albuquerque, said the focus should “shift toward things affecting outcomes regardless of the primary technique.”
These include:
- A team-based approach with standardized treatment plan
- Early pain intervention (blocks from acute pain service or in ER)
- Early surgery with early mobilization
- Brain function monitoring (anesthetic depth)
- Hemodynamic monitoring (triple low physiological and anesthetic measurements)
- A geriatric medicine consult to assess best medical treatment as well as fragility, cognition, and delirium risks.
“Options are different for healthy, mobile, independently living folks versus the sicker and more debilitated,” Dr. Burstrom said.
Meanwhile, Dr. Coppens said peripheral nerve blocks are emerging as a promising adjunct regardless of the primary anesthetic technique.
“The clearest benefits of fascia iliaca, femoral nerve, or pericapsular blocks (like PENG), whether combined with general or neuraxial anesthesia, are improved analgesia during positioning and the early perioperative period, together with reduced opioid requirements," Dr. Coppens said. “Recent observational research has also reported associations between perioperative peripheral nerve blocks and lower rates of postoperative cardiovascular complications or myocardial injury in high-risk older patients with hip fracture. However, these findings are hypothesis-generating and require confirmation in prospective randomized studies before a causal or cardioprotective effect can be inferred.”
Still, this is interesting and biologically plausible, he said, potentially through improved pain control and attenuation of the stress response.
“This also represents a much more compelling area for investigation than the spinal-versus-general anesthesia debate itself,” Dr. Coppens said.
