Comparing Two Types of Anesthesia for Hip Fracture Surgery -- The REGAIN Trial

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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.

Objective

To compare the effects of spinal anesthesia versus general anesthesia on the ability to walk after surgery and other postoperative outcomes among older adults undergoing hip surgery

Study Design

This randomized controlled trial compared the effects of spinal anesthesia versus general anesthesia on new inability to walk 10 feet or death among older adults 60 days after hip fracture surgery. The primary outcome included death to account for potential survivorship bias.

Researchers randomized patients to receive either spinal anesthesia or general anesthesia during surgery for hip fracture. To assess outcomes, during the first three days of recovery, researchers interviewed patients each day about acute postoperative pain, delirium, and satisfaction with anesthesia care. Researchers also reviewed patient health records for intraoperative and postoperative complications, including death, up to 30 days after surgery. At approximately 60, 180, and 365 days after surgery, researchers surveyed patients by phone. They asked about their place of residence, need for assistive devices for walking, overall health and disability, chronic pain, and use of prescription pain medication.

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

Older patients who had orthopedic surgery, caregivers, a patient advocacy group, and professional medical societies that focus on care for older adults provided input throughout the study.

Results

After 60 days, patients receiving spinal anesthesia and patients receiving general anesthesia did not differ significantly in the composite measure of new inability to walk independently or death. This outcome occurred in 18.5% of patients who received spinal anesthesia versus 18% of patients who received general anesthesia.

Compared with patients receiving general anesthesia, patients receiving spinal anesthesia were more likely to report taking prescription pain medications at 60 days (relative risk [RR]=1.33; 95% confidence interval [CI]: 1.06, 1.65). They also reported higher worst and average pain levels only in the first 24 hours after surgery, but this difference was small (worst pain mean difference=0.40; 95% CI: 0.12, 0.68; average pain mean difference=0.43; 95% CI: 0.15, 0.72).

Other safety and tolerability outcomes did not differ significantly by anesthesia type at 60 days, 180 days, or at 365 days.

Limitations

Researchers anticipated that 34% of patients receiving general anesthesia would experience the outcome of new inability to walk independently or death. Because fewer patients experienced the primary outcome than anticipated, the study may have had a reduced ability to detect differences between the groups.

Conclusions and Relevance

In this study, patients receiving spinal and general anesthesia had similar recovery, safety, and tolerability outcomes following hip surgery. More patients receiving spinal anesthesia reported prescription analgesic use at two months.

Future Research Needs

Future research could examine how different anesthesia types affect outcomes for patients with certain pre-surgery comorbidities, such as dementia, who are less likely to enroll in studies.