Results Summary

What was the research about?

Hip fractures can be a serious problem for older adults. Within a year after a hip fracture, half of people who used to live on their own have either moved to a nursing home or died.

Treatment for a hip fracture typically requires surgery. Anesthesia keeps patients from feeling pain during surgery. In this study, the research team compared how two types of anesthesia used during hip fracture surgery affected patients’ recovery:

  • Spinal anesthesia. Doctors inject medicine in the spinal fluid to numb the lower body and block pain. Patients usually also get medicine to make them feel drowsy.
  • General anesthesia. Doctors give patients medicine through a vein or mask to bring on a sleep-like state.

What were the results?

The two anesthesia types didn’t differ in an outcome that combined the rate of a new inability to walk or death within two months of surgery. For both anesthesia types, 18 percent of patients had a new inability to walk or died.

Also, patients didn’t differ in:

  • Chronic pain or overall health and disability at 2, 6, and 12 months.
  • Returning to where they lived before surgery.
  • Length of hospital stay.
  • Delirium or other complications while in the hospital.
  • Satisfaction with anesthesia care.

Compared with patients who had general anesthesia, more patients who had spinal anesthesia took prescription pain medicine two months after surgery. They also had higher levels of pain within 24 hours of surgery. But this difference was small.

Who was in the study?

The study included 1,600 patients ages 50 and older receiving hip fracture surgery. All received care at one of 46 hospitals in the United States and Canada. Among patients, 90 percent were White, 8 percent were Black, and 2 percent were Asian; 2 percent were Hispanic. The average age was 78, and 67 percent were women.

What did the research team do?

The research team assigned patients by chance to receive spinal or general anesthesia. During the first three days after surgery, the team interviewed patients about their pain, delirium, and care satisfaction. At 2, 6, and 12 months after surgery, the team asked patients if they could walk at least 10 feet without help from another person. They also asked about their overall health, pain, and place of residence. The team reviewed patient health records for length of hospital stay, complications, and death.

Older patients who had bone or joint surgery, caregivers, a patient advocacy group, and medical societies for care for older adults gave input during the study.

What were the limits of the study?

The number of patients who had a new inability to walk or died after surgery was lower than the research team expected, which may have limited the study’s ability to detect differences between anesthesia types.

Future research could compare types of anesthesia for patients who are less likely to enroll in studies, like those with dementia.

How can people use the results?

Older patients and their doctors can use the results when considering anesthesia types for hip fracture surgery.

Final Research Report

View this project's final research report.

Engagement Resources

Journal Citations

Article Highlight: Each year, more than 300,000 adults in the United States break a hip and nearly all will need surgery. This study, which compared how general anesthesia and spinal anesthesia during hip fracture surgery affected recovery, found patients who received spinal anesthesia received fewer opioids in the operating room but had more pain and prescription pain medication use after surgery. These results were published in the Annals of Internal Medicine. Overall, patients with spinal anesthesia had slightly higher levels of pain (7.9 out of 10) compared to those who had general anesthesia (7.6). Further results showed spinal anesthesia patients were also 33 percent more likely than general anesthesia patients to still be taking prescription painkillers roughly two months out from their procedure.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study. 

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.   

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following: 

  • In general, the reviewers responded positively to this report and praised the researchers for their careful approach to the study. Most of the requests for changes were minor. 

  • The reviewers questioned the use of a composite outcome measure made up of two very different clinical outcomes: death or inability to walk after two months. The researchers explained that they included death in their composite outcome because, given the population, they wanted to avoid survivorship bias by only including patients who would have final outcome data. 

  • The reviewers asked the researchers to explain why they adjusted their study sample into groups by hospital, sex and fracture location when the study sample was randomized so there should not have been an imbalance between groups. The researchers stated that they were following best practices for trials using stratified randomization. They also noted that although they were able to stratify groups by sex and fracture location, some hospital sites had such low enrollment that they chose to stratify by country of enrollment instead. 

  • The reviewers noted that some subgroups of individuals with hip fracture, such as people who could not walk on their own before surgery, were excluded from the study but may be the most vulnerable to negative outcomes based on anesthesia choice. The researchers acknowledged that the exclusion of these individuals was a limitation of the study, but also noted that only three percent of the overall patient population from which they recruited was non-ambulatory pre-surgery. The researchers also acknowledged that there was a smaller percentage of people with dementia in this study than in the national population of adults with hip fractures. They posited that people with dementia were less likely to agree to the study or less likely to complete study materials, so the study results may not be generalizable to that group. 

Conflict of Interest Disclosures

Project Information

Mark D. Neuman, MD, MS
University of Pennsylvania
$11,824,195
10.25302/07.2023.PCS.140618876
A Practical Intervention to Improve Patient-Centered Outcomes after Hip Fractures among Older Adults (Regain Trial)

Key Dates

April 2015
November 2023
2015
2023

Study Registration Information

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Last updated: February 22, 2024