Hip fractures, affecting primarily individuals aged ≥60 years and often result from osteoporosis or trauma. Effective perioperative pain management is essential to reduce opioid use, promote early mobilization, and minimize complications. General anesthesia (GA) has traditionally been used; studies suggest that regional anesthesia (RA). This literature review examines clinical studies comparing RA and GA in hip surgeries, focusing on pain scores, opioid consumption, complications, and postoperative recovery. A comprehensive search of PubMed and Google Scholar identified 11 relevant studies published based on inclusion and exclusion criteria. All these studies focus on perioperative pain management in hip surgeries. Findings highlight that RA techniques, especially peripheral nerve blocks, lead to reduced opioid consumption, lower pain scores, and faster recovery. RA was also associated with reduced complications like delirium and respiratory infections in elderly patients with hip fractures. Although both GA and RA are effective, regional anesthesia may be preferred in patients with specific comorbidities like pulmonary and cardiac disease. However, some studies demonstrated longer recovery times and increased incidence of urinary retention. Further research is needed to optimize protocols and minimize complications associated with RA techniques. Overall, regional anesthesia demonstrates superior pain management and recovery benefits, especially in elderly or high-risk patients, and should be considered as a preferred approach for hip surgeries.

Regional anesthesia, General anesthesia, Hip surgery, Perioperative pain, Complications.

Globally, approximately 1.5 million people suffer from hip fractures annually. These clinical fractures drastically enhance the incidence, specifically in adults aged≥60 years.[1] They have frequently occurred due to osteoporosis or trauma. These are considered severe injuries mainly due to their chronic pain, disability risk, and life-threatening complications. Hip surgeries, including total hip arthroplasty (THA), and remaining orthopedic techniques are significantly associated with post-operative pain, which is impacting different outcomes such as patients’ satisfaction, patients’ recovery, and quality of life. Hence, effective management of perioperative pain is essential to decrease consumption of opioids, to promote early mobilization, and to reduce complications like nausea, respiratory depression, and sedation.[2]

Hip surgery cases are most commonly found in low- and middle-income countries (LMICs). The use of neuraxial anesthesia has been observed to reduce blood loss during hip surgery and to lower the incidence of post-operative blood clots after lower limb surgery. Other potential benefits include improved analgesia, a shortened length of stay in post-anesthesia care units (PACU), and increased operating room (OR) efficiency.[3-6] These advantages can contribute to a reduction in the cost of care, which could help in LMICs. RA is also considered an important component of multimodal general anesthesia (MGA) by reducing the stress response to surgery and minimizing the need for opioids and their undesirable side effects through better analgesia.[7-10] Insufficiencies in anesthesia drugs and equipment limit anesthesia capacity in LMICs. Ultrasound-guided RA is useful in safe and reliable anesthesia in low-resource countries due to its durability, affordability, and user-friendliness.[11-13]

Conventionally, GA is a primary approach for hip surgeries. Nonetheless, various clinical studies support the use of RA as an adjunctive method for improving recovery and pain management. The use of RA for orthopedic procedures mitigates some of the complications associated with GA, like nausea, vomiting, airway trauma, hypoxia, respiratory depression, and the risk of pulmonary aspiration. With low systemic toxicity, the analgesic effect of RA has been proven in hip fractures and is expected to reduce delirium by controlling pain.[14-17]

Currently, several RA techniques such as fascia iliac block (FIB), lumbar plexus block, sciatic nerve block, femoral nerve block (FNB), and pericapsular nerve group (PENG) block are available for perioperative pain relief. The appropriate method for hip surgery is selected based on indication, institutional protocols, and patient characteristics.[18,19]

The objective of the review is to compare the effectiveness and safety of various RA with GA in patients undergoing hip surgery.

A comprehensive literature search was conducted using the primary databases like PubMed and Google Scholar by following criteria.

Inclusion criteria: Studies focused on hip surgeries, published within 10 years, clinical studies, and written in English.

Exclusion criteria: Certain types of publications, such as Books, reviews, meta-analyses, editorials, case reports, case series, and conference abstracts, were excluded.

Data extraction: Extract the data related to study design, patient population, and intervention groups, outcomes like pain scores, opioid consumption, hemodynamic data (systolic/diastolic blood pressure, heart rate), complications, postoperative recovery, mortality, and morbidity.

A total of 11 studies were selected for data extraction. The summary of each included study was as follows:

Kratz T et al.[20] conducted the German clinical trial (DRKS-ID: DRKS00000752) with ethical approval from the University Hospital of Marburg. A total of 52 patients who underwent elective hip surgery were included for final analysis. Patients were divided into the FNB and control group (general anesthesia). The FNB group showed lower systolic blood pressure (BP) during and after hip surgery and similarly lower diastolic BP post-operatively. Furthermore, heart rate, intake of opioids, and non-steroidal anti-inflammatory drugs (NSAIDs) were also reduced in the FNB group compared to the control. Hence, the Authors concluded that FNB showed improvement in perioperative hemodynamic stability mainly due to a reduction in sympathetic adrenergic response.

Chen K et al.[21] showed evidence of association between hip fractures in elderly patients and morbidity and mortality. The incorporation of peripheral nerve blocks in these patients leads to reductions in pain, risk of delirium, risk of respiratory infections, and time to mobilization. Large population-based studies also suggest a reduced length of hospital stay without significant increases in block-related adverse events. Authors recommended regional anesthesia FIB and FNB in all eligible patients with hip fractures. The choice of peripheral nerve block technique should consider variables such as contraindications, operator experience with the technique, and patient anatomy.

Esenyel AE et al.[22] aimed at the retrospective comparison of 850 cases that underwent total hip prosthesis (THP), partial hip prosthesis (PHP), and proximal femoral nail (PFN) treatments according to the chosen anesthetic method. Of 389 patients who received spinal anesthesia, 189 received combined spinal-epidural anesthesia, and 272 received general anesthesia. There were no significant differences found between the groups in terms of gender or American Society of Anesthesiologists (ASA) and postoperative intensive care requirements. The duration of surgery was shorter in the PFN group compared to the other two groups. General anesthesia was preferred more in the THP group, whereas regional anesthesia was more commonly used in the PFN group. Colloid use was greater in the PFN group, while the blood transfusion rate was higher in the THP group. Additionally, the THP group had a higher incidence of antihypertensive medication use compared to the other groups. In the PFN group, 4 patients experienced cardiac arrest during the operation. In the THP group, a central venous catheter was inserted in only 4 patients. For THP cases, higher sedation rates were administered during regional anesthesia.

Zhang G et al.[23] carried retrospective analysis of surgically treated intertrochanteric fracture patients, using propensity score matching (PSM) to investigate whether clinically relevant differences in outcomes were observed in mortality, complications, and functional outcomes between RA and GA. A total of 841 patients in the GA group and 1329 in the RA group were included. After PSM, 808 remained in each group. GA patients were more prone to have a shorter duration for their operation and higher total hospital costs than RA patients, with p-values of 0.034 and 0.004, respectively. They also found that the GA group has a higher rate of pulmonary complications (p = 0.017), whereas the RA group has a higher rate of cardiac complications (p = 0.011). There were no significant differences observed in mortality, functional outcomes, and other complications, with similar p > 0.05. This study finally concluded that the potential value of GA for patients with cardiac diseases and of RA for patients with pulmonary diseases.

Basdemirci A et al.[24] compared the effects of GA and RA techniques on the length of hospital stay and morbidity-mortality in geriatric patients (n = 331, age = >65 years) who underwent hip surgery. For the RA group, length of stay, blood loss, and necessity of blood transfusion were significantly lower compared to the GA group (p < 0.05). Moreover, GA mortality and morbidity rates were significantly higher compared to RA (p < 0.05). Finally, estimated that increased age and number of comorbid diseases enhanced the morbidity and mortality rates significantly with p value of <0.05).

Khan IA et al.[25] assessed the early postoperative mortality between general or regional anesthesia administered to patients (n = 60,897) who underwent either THA or PHA by a retrospective cohort study. In this 2015-2016 American College of Surgeons National Surgical Quality Improvement Program database was used. There was no evidence of an association between type of anesthesia and postoperative mortality in hip arthroplasty patients, regardless of whether the arthroplasty was partial (odds ratio [OR] = 0.85; confidence interval [CI] 0.59-1.22) or total (OR = 0.68; CI 0.43-1.08). The overall early postoperative mortality in adult hip arthroplasty patients is low in the absence of risk factors like severe congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), ascites, acute renal failure, and ASA score of 4 or higher. Finally, authors suggested that there was no association between the type of anesthesia received (general vs. regional) and early postoperative mortality rates in patients who underwent hip arthroplasty, regardless of type (total vs. partial).

Donauer K et al.[26] analyzed the international PAIN OUT registry for GA with RA about pain and morphine consumption on the first postoperative day. A total of 2,346 cases of knee arthroplasty and 2,315 cases of hip arthroplasty between 2010 and 2016 were identified in this registry study. Those were grouped according to anesthesia provided (general, regional, and a combination of both). After adjustment for confounders, RA was associated with reduced opioid consumption (OR 0.20 (95% CI 0.13 to 0.30), p < 0.001) and less pain (OR 0.53 (95% CI 0.36 to 0.78), p = 0.001) than was general anesthesia in knee surgery. In hip surgery, regional anesthesia was only associated with reduced opioid consumption (OR 0.17 (95% CI 0.11 to 0.26), p < 0.001), whereas pain was comparable (OR 1.23 (95% CI 0.94 to 1.61), p = 0.1). Results from a propensity-matched sensitivity analysis were similar. Finally concluded that RA was associated with less pain and lower opioid consumption in total knee arthroplasty. In total hip arthroplasty, RA was associated with lower opioid consumption, but not with reduced pain levels.

Kraus M et al.[27] performed retrospective analysis in 92 patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) with labral tears under GA with fascia-iliaca block (n = 64) or RA with fascia-iliaca block (n = 28) from March 9, 2016, to April 9, 2018. Patients who underwent hip arthroscopy under RA reported significantly less first (G: 3.4 (3.9), R: 1.3 (3.0), p = 0.0085) and average (G: 3.8 (2.5), R: 2.0 (2.2), p = 0.0038) pain post-operatively. Patients under RA also received less total morphine milligram equivalents (MME) intraoperatively and post-operatively (G: 40.8 (21.7) MME, R: 24.9 (17.8), p = 0.004). Patients under RA had a significantly higher incidence of urinary retention (G: 3.1%, R: 28.6%, p = 0.009) and increased time spent in PACU (G = 181.9 (86.3), R: 251.4 (80.4), p = 0.0001). The administration of RA resulted in significantly lower pain scores and perioperative opioid consumption compared to GA in patients. This may be the optimal anesthetic technique for pain control; however, the incidence of urinary retention and time to discharge are significantly increased.

Aygun H  et al.[28] explored the effect of PENG block on pain scores, opioid intake, time to first analgesic requirement, and quality of recovery within the first 24 h following surgery. Patients who underwent PENG had statistically significantly lower Numeric Rating Scale (NRS) scores after interventions, immediately before positioning, at positioning, and at the end of spinal anesthesia. Pain scores during positioning for spinal anesthesia were statistically significantly lower in the PENG group (n = 42) than in the control group (n = 42) with p-value of < 0.001. Total morphine use over the first 24 h was extremely statistically significantly lower in the PENG group (p < 0.001). High patient satisfaction was observed in patients who underwent PENG block.

Abduallah MA et al.[29] examined the effect of ultrasound-guided Erector Spinae Plane Block (ESPB) on postoperative analgesia after pediatric hip surgery (NCT04871061). In a trial with 40 children scheduled for hip surgery, participants were randomly assigned to either a control group (sham ultrasound-guided ESPB at L3) or an ESPB group (real ultrasound-guided ESPB at L3 with 0.4 ml/kg of plain bupivacaine 0.25%). The study recorded various outcomes, including time to first rescue analgesia request, intraoperative fentanyl consumption, postoperative morphine use, and pain scores (Children’s Hospital Eastern Ontario Pain Scale [CHEOPS], Objective Behavioral Pain score [OPS]). ESPB significantly prolonged time to first analgesic request (256.50 ± 66.434 min), reduced intraoperative fentanyl (0.775 ± 0.343 μg/kg) and postoperative morphine (0.065 ± 0.023 mg/kg) consumption, and decreased postoperative pain scores.

Casas Reza P et al.[1] demonstrated the postoperative pain following total hip arthroplasty, comparing outcomes with and without peripheral nerve blocks (FNB, fascia iliaca block, and PENG). Data were collected retrospectively from 656 patients who underwent trauma surgery between April 2018 and August 2020. Of the 362 eligible patients, the main indication was coxarthrosis (61.3%). Peripheral nerve blocks were used in 169 patients, with a lower average postoperative opioid consumption in those receiving PENG (2.2 mg) or femoral (3.27 mg) blocks compared to controls (6.69 mg). Nerve injury and prolonged quadriceps paralysis were rare, with the latter more common in femoral block patients. The study supports regional blocks as effective, opioid-sparing strategies with minimal motor impairment.

American Academy of Orthopaedic Surgeons (AAOS) guidelines recommended the use of multimodal analgesia, including preoperative nerve blocks, to manage pain effectively in patients undergoing hip surgeries. This approach has been shown to improve preoperative pain control and reduce the need for opioid analgesics.[30]

Table 1: Summary of key findings on anesthesia techniques and postoperative outcomes

The comparison between RA and GA in hip surgeries has been extensively studied, revealing important insights into their respective advantages and limitations. The extracted studies provide a comprehensive understanding of their impact on perioperative outcomes, including pain management, opioid consumption, hemodynamic stability, complication rates, and recovery times.

Pain management and opioid reduction: Several studies highlight the superior pain management benefits of RA, particularly peripheral nerve blocks. Kratz et al.[20] demonstrated that FNB improved hemodynamic stability and reduced opioid and NSAID consumption. Similarly, Donauer et al.[26] and Casas Reza et al.[1] showed that patients receiving RA required significantly lower postoperative opioid doses than those who underwent GA. Aygun et al.[28] found that the PENG block significantly decreased pain scores and opioid use, leading to high patient satisfaction. These findings support the role of RA in multimodal analgesia, aligning with recommendations from the AAOS to reduce opioid reliance in hip surgeries.

Complications and risk factors: RA has been associated with a lower incidence of certain complications compared to GA. Chen et al.[21] reported that RA was linked to a reduced risk of postoperative delirium, respiratory infections, and shorter hospital stays. Similarly, Basdemirci et al.[24] found that RA resulted in lower blood loss, a reduced need for transfusions, and decreased morbidity and mortality, particularly in geriatric patients. In contrast, Zhang et al.[23] observed that while GA was associated with increased pulmonary complications, RA patients experienced more cardiac complications. Kraus et al.[27] noted that while RA reduced pain scores and opioid consumption, it also increased urinary retention rates and prolonged post-anesthesia care unit (PACU) time. These findings emphasize the need to tailor anesthesia choices based on individual patient comorbidities and surgical contexts.

Impact on recovery and length of stay: RA has been shown to enhance recovery outcomes and reduce hospital stays in certain patient populations. Chen et al. and Basdemirci et al. reported that RA patients experienced shorter hospitalizations, facilitating earlier mobilization. In contrast, Esenyel et al.[22] found that while RA was frequently used in PFN surgeries, GA remained the preferred choice for THP cases, potentially due to surgical complexity and patient characteristics. Despite these advantages, Kraus et al.[27] noted that patients receiving RA spent a longer time in the PACU, which could delay early discharge.

Mortality and long-term outcomes: Khan et al.[25] analyzed a large cohort and found no significant difference in early postoperative mortality between GA and RA in hip arthroplasty patients, suggesting that both techniques are generally safe when appropriately applied. Zhang et al.[23] similarly found no significant differences were found in mortality rates or long-term functional outcomes between the two anesthesia techniques. However, given the variability in study designs, further research is required to assess the long-term effects of RA and GA on functional recovery, chronic pain management, and overall quality of life.

Limitations
Sample size: Some studies, such as Khan IA et al.[25] With 60,897 patients, rely on large databases, whereas some studies, like Aygun H et al.[28] with small sample sizes (n = 42) in each group, which are difficult to detect significant differences in outcomes and complications.

Heterogeneity of Interventions: The variation in anesthesia techniques (e.g., FNB, PENG, fascia-iliaca block, combined spinal-epidural, etc.) across studies could make it difficult to draw universal conclusions regarding the efficacy and safety of regional anesthesia. The technique, dose, and application of regional anesthesia vary widely, which can influence results.[1,2]

Inconsistency in outcome measurements: Different studies used various tools to evaluate the pain. Pain is measured using NRS in Aygun H et al.[28] while other studies use visual analog scales (VAS) or other assessment tools. This led to heterogeneity in reporting the results.

Confounding factors: Some studies, like Zhang G et al.[23] used PSM to correlate with age, comorbidities, and disease severity. But residual confounding factors are also considered for further research study.

Heterogeneity of patient populations: Several studies focus on older patients or those with comorbidities, which limit the outcome measures. Basdemirci A et al.[24] included geriatric patients while Abduallah MA et al.[29] (focused on pediatric patients.

Follow-up: Many studies lack long-term follow-up to evaluate the sustained effects of GA on outcomes, including functional recovery, long-term pain management, and complications. Donauer K et al.[26] focused mainly on the immediate postoperative period.

Future Research
Future research must focus on multi-center and large-scale clinical studies to decrease bias. Long-term follow-up studies are needed to determine the mobility, post-operative quality of life, and chronic pain. Cost-effectiveness analysis and comparative studies should be implemented between various GA methods. Research should focus on patient factors such as age, comorbidities, and anatomy of hip fractures. It’s essential to investigate rare adverse events such as cardiac complications and nerve injury.

In conclusion, the evidence suggests that RA, particularly peripheral nerve blocks, offers significant benefits in terms of pain management, opioid reduction, and improved recovery times in hip surgery patients. However, there are some trade-offs, such as potential increases in recovery time or urinary retention, that must be considered when selecting an anesthetic approach. RA may be especially beneficial in high-risk or elderly patients; however, the choice of technique should be tailored to the individual patient’s needs and surgical circumstances.

Not reported

Not applicable

Corresponding Author:
Suresh Srinivasan
Department of Anesthesiology
Trinity Health System, Steubenville, OH 43952, United States
Email: Suresh.Srinivasan@commonspirit.org

Co-Authors:
Raziya Begum Sheikh
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India
Email: raziya.pharma@gmail.com

Samatha Ampeti
Department of Pharmacology
Kakatiya University, University College of Pharmaceutical Sciences, Warangal, TS, India
Email: ampetisamatha9@gmail.com

Mansi Srivastava
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India
Email: srivastavamansi811@gmail.com

Sonam Shashikala B V
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India
Email: venkateshsonams@gmail.com

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

Not applicable

The authors declare no conflict of interest.

None

https://doi.org/10.63096/medtigo3067112

Raziya BS, Samatha A, Mansi S, Sonam SBV, Suresh S. A Comprehensive Review of Regional vs. General Anesthesia in Hip Surgery: Efficacy and Safety Outcomes. medtigo J Anesth Pain Med. 2025;1(1):e3067112. doi:10.63096/medtigo3067112 Crossref