Spinal anesthesia is a grossly underutilized gold standard in primary total joint arthroplasty: propensity-matched analysis of a national surgical quality database

BACKGROUND: There is currently no consensus regarding the optimal anesthetic technique for total hip and knee arthroplasty (THA, TKA). This study aimed to compare the utilization rates and safety of spinal vs. general anesthesia in contemporary THA/TKA practice. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a retrospective review of 307,076 patients undergoing total hip or knee arthroplasty under either spinal or general anesthesia between January 2015 and December 2018 was performed. Propensity matching was used to compare differences in operative times, hospital length of stay, discharge destination, and 30-day adverse events. The annual utilization rates for both techniques between 2011 and 2018 were also assessed. RESULTS: Patients receiving spinal anesthesia had a shorter length of stay (P < 0.001) for TKA while no statistical differences in length of stay were observed for THA. Patients were also less likely to experience any 30-day complication (OR = 0.82, P <0.001 and OR = 0.92, P < 0.001 for THA and TKA, respectively) while being more likely to be discharged to home (OR = 1.46, P < 0.001 and OR = 1.44, P < 0.001 for THA and TKA, respectively). Between 2011 and 2018, spinal anesthesia utilization only increased by 1.4% for THA (P < 0.001) and decreased by 0.2% for TKA (P < 0.001), reaching 38.1% and 40.3%, respectively. CONCLUSION: Spinal anesthesia remains a grossly underutilized tool despite providing better perioperative outcomes compared to general anesthesia. As orthopedic surgeons navigate the challenges of value-based care, spinal anesthesia represents an invaluable tool that should be considered the gold standard in elective, primary total hip and knee arthroplasty.