Abstract
Introduction:
Spinal anesthesia is increasingly used in complex patient populations including revision total hip arthroplasties (THAs). This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anesthesia in a large institutional series of revision THAs.
Methods:
We retrospectively identified 4,767 revision THAs (4,533 patients) from 2001 to 2016 using our institutional total joint registry. Of these cases, 86% had general and 14% had spinal anesthesia. Demographics between groups were similar with mean age of 66 years, 52% women, and mean BMI of 29. Complications including all-cause re-revisions and reoperations were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that accounted for patient and surgical factors. The mean follow-up was 7 years.
Results:
Patients treated with spinal anesthesia required fewer postoperative oral morphine equivalents (OMEs) (P<0.001) and had lower numeric pain rating scale scores (P<0.001). Spinal anesthesia had a decreased LOS (4.2 vs. 4.8 days; P=0.007), fewer cases of altered mental status (AMS; Odds Ratio (OR) 3.1, P=0.001), fewer blood transfusions (OR 2.3, P<0.001), fewer intensive care unit (ICU) admissions (OR 2.3, P<0.001), fewer re-revisions (OR 1.6, P=0.04), and fewer reoperations (OR 1.5, P=0.02).
Discussion:
Spinal anesthesia was associated with lower OME use and reduced LOS in this large cohort of revision THAs. Furthermore, spinal anesthesia was associated with fewer cases of AMS, transfusion, ICU admission, re-revision, and reoperation after accounting for numerous patient and operative factors.
Level of Evidence:
Level III, Retrospective Comparative Study
Keywords: Neuraxial anesthesia, total joint arthroplasty, revision, pain, opioids
INTRODUCTION
Spinal anesthesia has emerged as a safe and often preferred technique in primary total hip arthroplasties (THAs) [1–3]. Data from single institutions and databases alike have suggested several advantages of spinal anesthesia in comparison to general anesthesia including improved postoperative pain control, reduced opioid consumption, reduced hospital length of stay (LOS), and fewer postoperative adverse events [1, 4–7]. Nevertheless, despite evidence of increasing demand for revision THAs, data regarding the influence of anesthetic technique on outcomes following revision THAs are limited [5, 8].
Recently, studies utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) suggested spinal anesthesia was associated with several advantages in both aseptic and septic revision THAs [9, 10]. These benefits included reduced readmissions, reoperations, transfusions, surgical site infections, and even postoperative mortalities [9, 10]. Nevertheless, only modest gains were observed in terms of LOS, operative time, and blood loss when evaluated at the institutional level [11].
Due to the relative paucity of data regarding the effect of anesthesia following revision THAs, the present study aimed to determine the incidence of spinal and general anesthesia over a 15-year period, and to evaluate the impact of anesthetic selection on pain control, LOS, and complications following revision THAs from a single, high-volume academic center.
PATIENTS AND METHODS
Patients
A retrospective review of our institutional total joint registry was performed of patients undergoing revision THAs from January 1, 2001 to December 31, 2016 [12]. Revision THAs performed for neoplastic causes were excluded. Institutional review board approval was obtained prior to initiation of the study.
There were 4,767 revision THAs (4,533 patients) met inclusion criteria. Patients were divided into cohorts consisting of those treated with general anesthesia (86%) or spinal anesthesia (14%). Demographics between cohorts were comparable with a mean age of 66 years (range, 19 to 98), 52% women, and mean body mass index of 29 (range, 15 to 73) (Table 1). Within 2 years of the revision THA, 219 patients died (4.8%), 304 hips were re-revised (6.3%), and 376 hips (7.9%) had less than 2 years of follow-up and were considered lost to follow-up. Among the remaining patients, mean follow-up was 7 years (range, 2 to 18).
Table 1.
Patient Demographics and Surgical Characteristics
| Variables | General (N=4,109) | Spinal (N=658) | P value |
|---|---|---|---|
|
| |||
| Age at revision THA (years), Mean (range) | 66 (19 to 98) | 65 (23 to 93) | 0.361 |
| BMI Mean (range) | 29.7 (14.5 to 72.7) | 28.8 (15.8 to 64.1) | 0.00011 |
| Women, No. (%) | 2184 (53) | 340 (52) | 0.482 |
| Operative Time (minutes), Mean (range) | 190 (40 to 904) | 127 (45 to 464) | <0.00011 |
| CCI, Mean (SD) | 4.1 (3) | 3.6 (3) | <0.00011 |
| Aseptic Revision, No. (%) | 3,473 (85) | 599 (91) | <0.00012 |
| Non-modular Revision, No. (%) | 3,208 (78) | 462 (70) | <0.00012 |
| Both Component Revision, No. (%) | 1,226 (30) | 125 (19) | <0.00012 |
THA = total hip arthroplasty; SD = standard deviation; BMI = body mass index; CCI = Charlson Comorbidity Index
Unequal Variance T-Test;
Chi-SquareT
The numeric pain rating scale (NPRS) score was utilized to assess patient reported pain from postoperative day #0 (POD#0) until discharge. Pain was further evaluated by oral morphine equivalents (OMEs) which were reported from the post anesthesia care unit (PACU) until discharge. Intraoperative opioid administration was excluded from these calculations. Postoperative outcomes including altered mental status (AMS) events, blood transfusions, postoperative urinary retention requiring catheterization, intensive care unit (ICU) admissions, venous thromboembolic events, 30-day readmissions, and 90-day readmissions were collected using an institutional anesthesia database. Arthroplasty-specific adverse events including all-cause re-revision and reoperation were collected via our institutional total joint registry [12].
Data analyses
Data were summarized using means and standard deviations (SDs) for continuous variables and counts and percentages for categorical variables. Data were analyzed using an inverse probability of treatment weighting (IPTW) approach based on a propensity score that accounted for age at surgery, sex, BMI, American Society of Anesthesiologists (ASA) score, Charlson comorbidity Index (Severity and Age weighted), indication for surgery, operative time, modular versus non-modular revision, septic versus aseptic revision, surgeon use of spinal anesthesia, and year of surgery [13]. The IPTW statistical method balances the distribution of confounding variables (e.g., age, ASA score, indication for surgery, year of surgery) between spinal and general anesthesia cohorts by assigning a weight that is inversely proportional to the probability of a patient being treated with the respective anesthetic technique [14]. The goal of this approach was to balance the systematic differences between the cohorts with respect to the confounding variables reported [15]. Continuous outcomes (e.g., NPRS scores, OMEs, and LOS) were compared between the spinal and general groups using IPTW general linear models. Binary outcomes (e.g., blood transfusion, urinary retention, and ICU admission) were analyzed using IPTW logistic regression. Time to event outcomes (e.g., all-cause re-revision and reoperation) were analyzed using survivorship methodology, including Kaplan-Meier estimation and IPTW Cox regression. The statistical analysis system (SAS) software version 9.4 (SAS Institute Inc., Cary, North Carolina) was used to perform all statistical analyses.
RESULTS
Incidence
Throughout the study period utilization of spinal anesthesia in revision THAs was relatively low at our institution (Figure 1). From 2001 to 2008, greater than 85% of revision THAs were performed under a general anesthetic. After 2008, there was a positive trend towards increased use of spinal anesthesia in revision THAs with maximum usage (24% of revision THAs) occurring in 2016 (Supplementary Table 1).
Figure 1.
Yearly percentage of revision total hip arthroplasties (THAs) treated with spinal vs. 3 general anesthesia during the study period.
Pain
Patients treated with spinal anesthesia reported reduced mean NPRS scores at all time points studied (e.g., PACU and POD#0 to #2) (Table 2). The absolute difference in mean NPRS scores was largest POD#0, but persisted throughout the inpatient stay (Table 2). In addition to reduced NPRS scores, patients treated with spinal anesthesia also consumed fewer opioids at all time points evaluated. The greatest difference in mean OMEs consumed was observed in first 24 hours with a 36% reduction in OMEs and this trend persisted throughout the LOS with patients treated with spinal anesthesia consuming 30% fewer OMEs per day of inpatient stay (Table 2).
Table 2.
Pain Control after Revision THA
| Outcome | Type | IPTW |
|
|---|---|---|---|
| LS Means | p-value | ||
|
| |||
| Mean Pain Scores, POD#0 | General | 3.67 | <0.001 |
| Spinal | 2.57 | ||
| Mean Pain Scores, POD#1 | General | 3.14 | 0.04 |
| Spinal | 2.86 | ||
| Mean Pain Scores, POD#2 | General | 2.89 | 0.006 |
| Spinal | 2.57 | ||
| Mean Pain Score, Overall Hospital Stay | General | 3.14 | <0.001 |
| Spinal | 2.31 | ||
| PACU OME | General | 16.62 | <0.001 |
| Spinal | 8.78 | ||
| 24-Hour OME | General | 68.79 | 0.0003 |
| Spinal | 43.55 | ||
| 24–48 Hour OME | General | 37.67 | 0.02 |
| Spinal | 23.66 | ||
| Total Hospital Stay OME | General | 229.22 | <0.001 |
| Spinal | 138.49 | ||
| Mean Per Day Hospital Stay OME | General | 49.08 | 0.0002 |
| Spinal | 34.32 | ||
THA=Total hip arthroplasty; IPTW=Inverse probability of treatment weighted model based on propensity score; LS=Least squares; POD=Postoperative day; PACU=Post anesthesia recovery unit; OME=Oral morphine equivalents
Length of Stay
In regard to length of stay, mean time spent in the PACU was significantly less in patients treated with spinal anesthesia (spinal: 125 vs. general: 146 minutes, P<0.001). Similarly, patients treated with spinal anesthesia demonstrated reduced hospital LOS compared to the general anesthesia cohort (4.2 vs. 4.8 days, respectively; P=0.002).
Postoperative Outcomes
Increased rates of several in-hospital complications were observed with general anesthesia utilization (Table 3). Specifically, general anesthesia was associated with more AMS events (OR 3.1, P=0.001), blood transfusions (OR 2.3, P<0.001), and ICU admissions (OR 2.3, P=0.001) (Table 3). Notably, patients treated with general anesthesia were less likely to experience urinary retention requiring catheterization (OR 0.7, P=0.049)
Table 3.
Inpatient Outcomes after Revision THA
| Outcome | Type | N | Events | IPTW |
|
|---|---|---|---|---|---|
| OR (95% CI) | p-value | ||||
|
| |||||
| AMS/Delirium | Spinal | 658 | 13 | reference | |
| General | 4109 | 238 | 3.1 (1.60, 5.90) | 0.001 | |
| Blood | Spinal | 658 | 63 | reference | |
| Transfusion | General | 4109 | 857 | 2.3 (1.61, 3.22) | <0.001 |
| Urinary | Spinal | 658 | 224 | reference | |
| Retention | General | 4109 | 901 | 0.77 (0.59, 1.0) | 0.049 |
| ICU Admission | Spinal | 658 | 24 | reference | |
| General | 4109 | 438 | 2.3 (1.40, 3.90) | 0.001 | |
THA = Total hip arthroplasty; IPTW = Inverse probability of treatment weighted model based on propensity score; OR = Odds ratio; CI = Confidence interval; AMS = Altered mental status; ICU = Intensive care unit
Regarding post-discharge outcomes, there was no difference in the rate of deep vein thrombosis, pulmonary emboli, 30-day readmissions, or 90-day readmissions between anesthetic cohorts (Table 4). The data did suggest an increased risk of all-cause re-revision (hazard ratio (HR) 1.6, P=0.04) and all-cause reoperation (HR 1.5, P=0.02) when treated with general anesthesia (Table 4).
Table 4.
Post-discharge Outcomes after Revision THAs
| Outcome | Type | N | Events | IPTW |
|
|---|---|---|---|---|---|
| HR (95% CI) | p-value | ||||
|
| |||||
| Pulmonary Embolism | Overall | 4767 | 15 | N/A | |
| Spinal | 658 | 1 | reference | ||
| General | 4109 | 14 | 1.3 (0.18, 10.28) | 0.774 | |
| Deep Vein Thrombosis | Overall | 4767 | 30 | N/A | |
| Spinal | 658 | 4 | reference | ||
| General | 4109 | 26 | 1.6 (0.41, 6.02) | 0.503 | |
| Readmission within 30 days | Overall | 4767 | 152 | N/A | |
| Spinal | 658 | 15 | reference | ||
| General | 4109 | 137 | 1.4 (0.80, 2.56) | 0.230 | |
| Readmission within 90 days | Overall | 4767 | 236 | N/A | |
| Spinal | 658 | 28 | reference | ||
| General | 4109 | 208 | 1.3 (0.79, 1.92) | 0.366 | |
| All-cause Reoperation | Overall | 4767 | 765 | N/A | |
| Spinal | 658 | 72 | reference | ||
| General | 4109 | 693 | 1.5 (1.07, 2.08) | 0.018 | |
| All-cause Revision | Overall | 4767 | 539 | N/A | |
| Spinal | 658 | 52 | reference | ||
| General | 4109 | 487 | 1.6 (1.03, 2.37) | 0.037 | |
THA = Total hip arthroplasty; IPTW = Inverse probability of treatment weighted model based on propensity score; HR = Hazard ratio; CI = Confidence interval
DISCUSSION
The influence of spinal vs. general anesthesia on postoperative outcomes following primary THAs are well-recognized, and current consensus recommendations actually favor spinal anesthesia use when medically safe and appropriate in primary THAs [1–3]. However, there are limited data to suggest this recommendation should extend to the revision THA patient. With this in mind, the present study evaluated 4,767 revision THAs from a single institution and suggests spinal anesthesia affords advantages regarding postoperative pain control and reduced rates of several adverse outcomes in comparison to similar patients treated with a general anesthetic.
In this study, patients treated with spinal anesthesia reported reduced NPRS scores and consumed fewer opioids from POD#0 throughout the inpatient hospital stay. To the authors knowledge, no previous study has directly studied the impact of anesthetic technique on pain control postoperatively in the revision setting. Importantly, these data were comparable to previous reports in primary THAs where patient reported pain and opioid consumption was decreased if treated with spinal anesthesia [16, 17]. Analogous to previous reports in primary THAs, the differences in NPRS scores were modest (i.e., 1-point difference) which falls below the suggested minimal clinically important difference (MCID) of the NPRS (i.e., 2-point difference) [18]. Nevertheless, the observed differences in patient reported pain also coincided with reductions in opioid consumption suggesting a true pain benefit.
Refined perioperative protocols in primary THAs have led to renewed interest in optimizing patient care pathways following revision THAs [19, 20]. In the present investigation, patients treated with spinal anesthesia experienced a mean reduction in hospital LOS of 0.6 days. Similar results were reported in a single institution study with a comparable reduction of 0.75 days following revision THA [11]. In contrast, data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database showed no difference in LOS associated with anesthetic choice for patients undergoing revision THA for aseptic or septic indication [9, 21]. Ultimately, the reasons for or against prolonged LOS in this study or prior cohorts remains uninvestigated in the revision setting as no study comparing anesthetic cohorts has evaluated differences in other factors that may affect time to discharge (e.g., rehabilitation protocols) [9–11].
The present investigation suggested an association between many adverse events and the utilization of general anesthesia in revision THAs. From the inpatient perspective, this studies data suggested increased risk of AMS events, blood transfusions, and ICU admissions if treated with general anesthesia. The inpatient findings are corroborated by data from a single institution study by Tirumala et al.[11] which demonstrated increased risk of blood transfusions and overall complication rate in revision THAs treated with general anesthesia. Additionally, data from three separate ACS NSQIP studies showed decreased rates of blood transfusions and postoperative complications associated with spinal anesthesia usage in revision THAs [9, 10, 22].
In addition to differentiated outcomes for inpatients, this study demonstrated increased risk of post-discharge complications including all-cause re-revision and reoperation in patients treated with general anesthesia. A prior investigation by Wilson et al.[10] evaluated aseptic revision THAs and showed a reduced incidence of several adverse events including readmissions, surgical site infections, and reoperations when treated with a spinal anesthetic. Similarly, Serino et al.[9] evaluated a cohort of revision THAs and determined spinal anesthesia was associated with fewer overall adverse events including superficial and deep surgical site infections. To the authors knowledge, no other study has evaluated the rate of all-cause re-revision in relation to anesthetic choice. The present investigation favored spinal anesthesia in this regard; however, the exact mechanism of this finding requires further evaluation.
The present study has several potential limitations. This was a retrospective review in which the specific indications for the anesthetic technique utilized were unknown and varied with surgeon and/or anesthesiologist preference as well as year of surgery. In the current study, relative utilization of spinal anesthesia was low throughout the study period ranging from 7 to 24% of revision THAs per year. In part, patient positioning (e.g., lateral) may have influenced providers to use a general anesthetic with greater airway control; however, there may also be patient factors (e.g., obesity, anticoagulation history, and neurologic history) known to influence anesthetic technique selection which were not accounted for in this study. Additionally, baseline characteristics differed between anesthetic cohorts, and this introduces the risk for selection bias in our study. Specifically, patients treated with spinal anesthesia were more likely to have lower BMIs and lower Charlson comorbidity indices than patients treated with general anesthesia (Table 1). Likewise, from an operative perspective, patients treated with spinal anesthesia had shorter operative times and were more likely to be indicated for surgery for aseptic, modular, and single component revisions (Table 1). Taken together, these differences suggest that patients treated with general anesthesia represented a less healthy and more complex patient population and this must be considered when interpreting the results of the present study. To reduce biases, an IPTW model based on propensity score was created which included numerous patient and operative factors. Despite these efforts, bias may persist and impact the reported outcomes. Recognizing these limitations, the methodology employed in this study allowed for the assessment of nearly 5,000 consecutive revision THAs which to the best of our knowledge, represents the largest single institution investigation to date.
In conclusion, our series of revision THAs comparing spinal and general anesthesia suggested several benefits of spinal anesthesia in comparison to general anesthesia. These benefits included improved patient report pain and reduced inpatient opioid consumption at all time points evaluated. Moreover, spinal anesthesia was associated with fewer inpatient and post-discharge adverse outcomes including reduced altered mental status events, intensive care unit admissions, postoperative transfusions, all-cause re-revisions, and all-cause reoperations. Spinal anesthesia may offer advantages in revision THAs when medically appropriate.
Supplementary Material
Supplementary Table 1. General and Spinal Anesthesia Percent Utilization by Year of Surgery
ACKNOWLEDGMENTS
The authors would like to acknowledge the Andrew A. and Mary S. Sugg Professorship in Orthopedic Research for its philanthropic support that made such research possible.
We thank Dirk R. Larson, M.S. for his statistical expertise. Additionally, we thank Youlonda A. Loechler and the members of the Mayo Clinic Total Joint Registry for her contributions to this study.
Funding:
Dr. Daniel J Berry is funded by grants from the National Institutes of Health (R01AR73147, R01HL147155), NIAMS (P30AR76312). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REFERENCES
- 1.Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Hargett MJ, Lee BH, Wendel P, Brouillette M, Go G, Kim SJ, Baaklini L, Wetmore D, Hong G, Goto R, Jivanelli B, Argyra E, Barrington MJ, Borgeat A, De Andres J, Elkassabany NM, Gautier PE, Gerner P, Gonzalez Della Valle A, Goytizolo E, Kessler P, Kopp SL, Lavand’Homme P, MacLean CH, Mantilla CB, MacIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Pichler L, Poeran J, Poultsides LA, Sites BD, Stundner O, Sun EC, Viscusi ER, Votta-Velis EG, Wu CL, Ya Deau JT, Sharrock NE. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. British journal of anaesthesia 123(3): 269, 2019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Johnson RL, Kopp SL, Burkle CM, Duncan CM, Jacob AK, Erwin PJ, Murad MH, Mantilla CB. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. British journal of anaesthesia 116(2): 163, 2016 [DOI] [PubMed] [Google Scholar]
- 3.Hannon CP, Keating TC, Lange JK, Ricciardi BF, Waddell BS, Della Valle CJ. Anesthesia and Analgesia Practices in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership. The Journal of arthroplasty 34(12): 2872, 2019 [DOI] [PubMed] [Google Scholar]
- 4.Johnson RL, Frank RD, Habermann EB, Chamberlain AM, Abdel MP, Schroeder DR, Mantilla CB. Neuraxial anesthesia is associated with improved survival after total joint arthroplasty depending on frailty: a cohort study. Regional anesthesia and pain medicine 45(6): 405, 2020 [DOI] [PubMed] [Google Scholar]
- 5.Weinstein SM, Baaklini LR, Liu J, Poultsides L, Cozowicz C, Poeran J, Saleh JN, Memtsoudis SG. Neuraxial anaesthesia techniques and postoperative outcomes among joint arthroplasty patients: is spinal anaesthesia the best option? British journal of anaesthesia 121(4): 842, 2018 [DOI] [PubMed] [Google Scholar]
- 6.Basques BA, Toy JO, Bohl DD, Golinvaux NS, Grauer JN. General compared with spinal anesthesia for total hip arthroplasty. The Journal of bone and joint surgery American volume 97(6): 455, 2015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Perlas A, Chan VW, Beattie S. Anesthesia Technique and Mortality after Total Hip or Knee Arthroplasty: A Retrospective, Propensity Score-matched Cohort Study. Anesthesiology 125(4): 724, 2016 [DOI] [PubMed] [Google Scholar]
- 8.Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of bone and joint surgery American volume 89(4): 780, 2007 [DOI] [PubMed] [Google Scholar]
- 9.Serino J 3rd, Galivanche AR, Grauer JN, Haynes M, Karas V, Della Valle CJ. General Versus Neuraxial Anesthesia in Revision Surgery for Periprosthetic Joint Infection. The Journal of arthroplasty 37(8s): S971, 2022 [DOI] [PubMed] [Google Scholar]
- 10.Wilson JM, Farley KX, Bradbury TL, Guild GN. Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database. Clinical orthopaedics and related research 478(1): 80, 2020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Tirumala V, Bounajem G, Klemt C, Maier SP, Padmanabha A, Kwon YM. Outcome of Spinal Versus General Anesthesia in Revision Total Hip Arthroplasty: A Propensity Score-Matched Cohort Analysis. The Journal of the American Academy of Orthopaedic Surgeons 29(13): e656, 2021 [DOI] [PubMed] [Google Scholar]
- 12.Berry DJ, Kessler M, Morrey BF. Maintaining a hip registry for 25 years. Mayo Clinic experience. Clinical orthopaedics and related research (344): 61, 1997 [DOI] [PubMed] [Google Scholar]
- 13.Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45(6): 613, 1992 [DOI] [PubMed] [Google Scholar]
- 14.Austin PC. The performance of different propensity-score methods for estimating differences in proportions (risk differences or absolute risk reductions) in observational studies. Stat Med 29(20): 2137, 2010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med 34(28): 3661, 2015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Donauer K, Bomberg H, Wagenpfeil S, Volk T, Meissner W, Wolf A. Regional vs. General Anesthesia for Total Knee and Hip Replacement: An Analysis of Postoperative Pain Perception from the International PAIN OUT Registry. Pain practice : the official journal of World Institute of Pain 18(8): 1036, 2018 [DOI] [PubMed] [Google Scholar]
- 17.Greimel F, Maderbacher G, Zeman F, Grifka J, Meissner W, Benditz A. No Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction. The Journal of arthroplasty 32(11): 3429, 2017 [DOI] [PubMed] [Google Scholar]
- 18.Farrar JT, Young JP Jr., LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94(2): 149, 2001 [DOI] [PubMed] [Google Scholar]
- 19.Deans CF, Buller LT, Ziemba-Davis M, Meneghini RM. Same-Day Discharge Following Aseptic Revision and Conversion Total Joint Arthroplasty: A Single-Institution Experience. Arthroplast Today 17: 159, 2022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Crawford DA, Lombardi AV Jr., Berend KR, Morris MJ, Adams JB. The feasibility of outpatient conversion and revision hip arthroplasty in selected patients. Hip Int 31(3): 393, 2021 [DOI] [PubMed] [Google Scholar]
- 21.Liodakis E, Bergeron SG, Zukor DJ, Huk OL, Epure LM, Antoniou J. Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database. The Journal of arthroplasty 30(11): 1868, 2015 [DOI] [PubMed] [Google Scholar]
- 22.DeMik DE, Carender CN, Glass NA, Brown TS, Callaghan JJ, Bedard NA. Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty? The Journal of arthroplasty 37(6s): S63, 2022 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Table 1. General and Spinal Anesthesia Percent Utilization by Year of Surgery