title: Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research.
abstract: BACKGROUND
  This systematic review evaluated the evidence comparing patient-important outcomes in spinal or epidural vs general anaesthesia for total hip and total knee arthroplasty.
  
  
  METHODS
  MEDLINE, Ovid EMBASE, EBSCO CINAHL, Thomson Reuters Web of Science, and the Cochrane Central Register of Controlled Trials from inception until March 2015 were searched. Eligible randomized controlled trials or prospective comparative studies investigating mortality, major morbidity, and patient-experience outcomes directly comparing neuraxial (spinal or epidural) with general anaesthesia for total hip arthroplasty, total knee arthroplasty, or both were included. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. Meta-analysis was conducted using the random-effects model.
  
  
  RESULTS
  We included 29 studies involving 10 488 patients. Compared with general anaesthesia, neuraxial anaesthesia significantly reduced length of stay (weighted mean difference -0.40 days; 95% confidence interval -0.76 to -0.03; P=0.03; I2 73%; 12 studies). No statistically significant differences were found between neuraxial and general anaesthesia for mortality, surgical duration, surgical site or chest infections, nerve palsies, postoperative nausea and vomiting, or thromboembolic disease when antithrombotic prophylaxis was used. Subgroup analyses failed to find statistically significant interactions (P>0.05) based on risk of bias, type of surgery, or type of neuraxial anaesthesia.
  
  
  CONCLUSIONS
  Neuraxial anaesthesia for total hip or total knee arthroplasty, or both appears equally effective without increased morbidity when compared with general anaesthesia. There is limited quantitative evidence to suggest that neuraxial anaesthesia is associated with improved perioperative outcomes. Future investigations should compare intermediate and long-term outcome differences to better inform anaesthesiologists, surgeons, and patients on importance of anaesthetic selection.
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA johnson.rebecca1@mayo.edu.
authors.forename: R L
authors.initials: RL
authors.lastname: Johnson
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: S L
authors.initials: SL
authors.lastname: Kopp
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: C M
authors.initials: CM
authors.lastname: Burkle
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: C M
authors.initials: CM
authors.lastname: Duncan
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: A K
authors.initials: AK
authors.lastname: Jacob
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: P J
authors.initials: PJ
authors.lastname: Erwin
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: M H
authors.initials: MH
authors.lastname: Murad
authors.affiliation: College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA.
authors.forename: C B
authors.initials: CB
authors.lastname: Mantilla
mesh_terms: D000767:Anesthesia, Epidural / Q000706:statistics & numerical data*; D000768:Anesthesia, General / Q000706:statistics & numerical data*; D000775:Anesthesia, Spinal / Q000706:statistics & numerical data*; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D057186:Comparative Effectiveness Research / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
keywords: anaesthesia, general; anaesthesia, spinal; pain, postoperative; postoperative complications