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INTRODUCTION
Hip fracture represents one of the significant challenges to healthcare in the 21st century. It is estimated that approximately 1.6 million people suffered from hip fractures globally in 2000, and this number is expected to rise to 4.5 million by 2050 due to the aging global population, imposing a substantial burden on both families and society 1-3. Despite patients receiving optimal care, the postoperative survival of elderly patients remains poor 4.
Almost all hip fracture patients undergo surgical treatment, and the choice of anesthesia can influence postoperative recovery and long-term prognosis 5. The application of regional anesthesia (RA) and general anesthesia (GA) in elderly patients with hip fractures has been debated. Approximately 60% of elderly patients receive GA, while 40% undergo spinal anesthesia (SA) or nerve blocks 6,7. RA is favored by clinicians as an integral part of multimodal analgesia due to its ease of administration and reduced opioid consumption compared to GA 8. Previous studies have shown that RA can reduce the incidence of postoperative cognitive dysfunction and the risk of death and major complications by limiting anesthesia and morphine use, compared to GA 9,10. However, the complexity of RA, the high requirement for patient cooperation, and potential local complications have limited its application in certain situations. GA provides a more stable anesthetic effect and better surgical conditions but is associated with physiological suppression, postoperative cognitive dysfunction, and respiratory complications, raising concerns about its safety in elderly patients.
In recent years, with the continuous advancement of anesthetic techniques and drugs, comparative studies on the application of RA and GA in hip fracture surgery in the elderly have increased. However, existing results are inconsistent, with some studies supporting the superiority of RA 9,10, while others consider GA and RA to have equivalent efficacy 11. This inconsistency may arise from differences in study design, patient population heterogeneity, and non-uniform postoperative assessment standards. This study aims to systematically evaluate and compare the efficacy and safety of RA and GA in hip fracture surgery in older patients through a meta-analys address. We will conduct a comprehensive analysis of existing randomized controlled trials to provide clinical physicians with a more scientific and objective basis for decision-making and improve the postoperative outcomes of elderly patients with hip fractures.
MATERIALS AND METHODS
In accordance with the PRISMA 2020 statement 12, a systematic search was conducted across four electronic databases: PubMed, Web of Science, Cochrane Library, and Embase. The search period was from the databases’ inception to August 20, 2024. The search strategy included the following keywords: “Hip fracture,” “General anesthesia,” “Regional anesthesia,” “Conduction Anesthesia,” “Local Anesthesia,” “Spinal anesthesia,” OR “Epidural anesthesia.” Additionally, targeted literature was identified by reviewing the reference lists of included studies.
Inclusion and exclusion criteria
Inclusion criteria: (1) Studies published in peer-reviewed journals in Chinese or English; (2) Study subjects were elderly patients aged ≥60 years (or with a majority aged ≥60 years) with hip fractures undergoing surgical treatment; (3) The experimental group received RA; (4) The control group received GA; (5) At least one of the following outcomes was reported: primary outcomes [surgical time, duration of anesthesia, blood loss, intraoperative transfusion (in units of packed red blood cells), and hospital length (from the day of admission to the day of discharge)], secondary outcomes [adverse events (intraoperative hypotension, postoperative cognitive dysfunction, intraoperative delirium, etc.)]; (6) Randomized controlled trials (RCT).
Exclusion criteria: (1) Non-population- based studies; (2) Conference papers, case reports, systematic reviews, and other study types; (3) Insufficient outcome information for data analysis; (4) Duplicate reporting of studies; (5) Studies where full-text articles could not be obtained.
Studies screening and data extraction
Two researchers independently conducted literature screening based on the inclusion and exclusion criteria. Initial screening was performed by reading the titles and abstracts of the literature, followed by a fulltext review of potentially eligible studies. In cases of disagreement between the two researchers, a third researcher was consulted, and a consensus was reached through discussion. After the literature screening, two researchers independently extracted data according to a predefined data extraction form, which included information on publication details, demographic characteristics of the study subjects, intervention characteristics, study period, and outcome events.
Quality assessment
The quality of the literature was assessed using the Cochrane Collaboration’s risk assessment tool13, which evaluates aspects such as the method of randomization, allocation concealment, blinding, completeness of outcome data, selective reporting of study results, and other sources of bias.
Statistical methods
Statistical analysis was performed using the Revman 5.3 software. Continuous data were expressed as mean differences (MD), and the effect size for categorical data was represented by the relative risk (RR), with the 95% confidence interval (CI) used to estimate the range of the effect size. Heterogeneity was assessed using the I2 statistic and Q-test to determine the degree of heterogeneity. The values of I2 <40%, I2 = 40-60%, and I2 > 60% indicated low, moderate, and high heterogeneity, respectively. If I2 was <50% or p>0.1, a fixed-effect model was used for analysis; if I2 was >50% or p≤0.1, a random-effects model was used for analysis. If significant heterogeneity was present, sensitivity analysis was conducted to explore the sources of heterogeneity. Unless otherwise specified, the significance level was set at p<0.05.
RESULTS
Basic information of included studies
After searching the electronic databases, 3792 studies were identified and included in the literature review process, as shown in Fig. 1. After excluding 1731 duplicate studies and 1964 irrelevant studies, 97 studies were reviewed in full text to determine their eligibility for this study, and ultimately, 14 qualified studies were included 11,14-26.
The publication years of the 14 RCTs spanned from 2003 to 2024, with four studies originating from China, two multi-country studies (USA and Canada), and the remaining studies from Israel (n=1), Iran (n=1), France (n=1), Greece (n=1), Korea (n=1), USA (n=1) Denmark (n=1) and the UK (n=1). The 14 studies involved 5626 elderly patients undergoing hip fracture surgery, of which 2768 patients received RA, and the remaining 2858 patients received GA. The average age of the study subjects ranged from 62.5 to 85 years, and in four studies, most of the patients were male (male≥50%). A summary of the basic information of the included studies is presented in Table 1.
Table 1 Basic information of eligible studies.
| Study | Location | Sample-RA | Sample-GA | Mean age | Male % | ASA |
|---|---|---|---|---|---|---|
| Rasmussen,2003 | Denmark | 211 | 217 | 70.8/71.1 | 84.36/88.02 | I-IV |
| Hoppenstein,2005 | Israel | 30 | 30 | 81.5/83.5 | NA | I-III |
| Parker,2015 | UK | 158 | 164 | 82.9/83.0 | 19.0/34.8 | NA |
| Shi,2015 | China | 50 | 50 | 68.3 | 43 | NA |
| Neuman,2016 | USA | 6 | 6 | 80.5/62.5 | 67/83 | NA |
| Haghighi,2017 | Iran | 50 | 50 | 66.22/65.98 | 84/76 | I-III |
| Meuret,2018 | France | 19 | 21 | 83/85 | 11/29 | I-III |
| Tzimas,2018 | Greece | 37 | 33 | 77.11/75.09 | 47.14 | I-III |
| Shin,2020 | Korea | 58 | 118 | 81.6/80.0 | 29.3/24.6 | NA |
| Tang,2021 | China | 55 | 55 | 78.00/76.60 | 29.1/36.4 | II-IV |
Quality of included studies
We utilized the Cochrane Risk of Bias tool to assess the quality of the included studies, revealing a significant risk of bias in the implementation of blinding and a potential risk in allocation concealment, as shown in Supplementary Figs. 1-2. Overall, the quality of the included studies was acceptable.
Surgical time
Eight studies provided results on the impact of different anesthesia methods on surgical time for elderly patients with hip fractures, involving 1,231 patients who received RA and 1,245 patients who received GA. The heterogeneity assessment showed heterogeneity among the included studies (I2=87%, p<0.00001), and the random-effects model was used to evaluate the impact of RA versus GA on surgical time. The meta-analysis results indicated no statistically significant difference in the impact of the two anesthesia methods on surgical time (MD: -3.10; 95%CI: -6.99, 0.79), as seen in Fig. 2.
Anesthesia time
Six studies provided results on the impact of different anesthesia methods on anesthesia time for elderly patients undergoing hip fracture surgery, involving 1,307 patients who received RA and 1,389 patients who received GA. The assessment of heterogeneity revealed heterogeneity among the included studies (I2=69%, p=0.006), and the random-effects model was used to calculate the pooled effect size. The results indicated no statistically significant difference in the impact of RA versus GA on anesthesia time for elderly hip fracture surgery patients (MD: -0.87; 95%CI: -4.25, 2.50), as shown in Fig. 3.
Blood Loss
Five studies provided results on the impact of different anesthesia methods on intraoperative blood loss for elderly patients undergoing hip fracture surgery, involving 1,169 patients who received RA and 1,245 patients who received GA. The assessment of heterogeneity revealed heterogeneity among the included studies (I2=97%, p<0.00001), and the random-effects model was used to calculate the pooled effect size. The results showed that, compared to GA, the use of RA in elderly patients during hip fracture surgery was associated with lower intraoperative blood loss (MD: -39.7 mL; 95%CI: -68.61, -10.84; p = 0.007), as depicted in Fig. 4.
Intraoperative transfusion
Five studies reported the impact of different anesthesia methods on intraoperative transfusion for elderly patients undergoing hip fracture surgery, involving 1,064 patients who received RA and 1,078 patients who received GA. The assessment of heterogeneity revealed heterogeneity among the included studies (I2=85%, p<0.0001), and the random-effects model was used to evaluate the impact of anesthesia methods. The meta-analysis results indicated no statistically significant difference in the impact of the two anesthesia methods on intraoperative transfusion for elderly hip fracture surgery patients (RR: 0.75; 95%CI: 0.41, 1.36), as illustrated in Fig. 5.
Hospital stay length
Five studies reported the impact of different anesthesia methods on postoperative hospital stay length for elderly patients who underwent hip fracture surgery, involving 932 patients who received RA and 1,004 patients who received GA. The assessment of heterogeneity revealed heterogeneity among the included studies (I2=69%, p=0.01), and the random-effects model was used to calculate the pooled effect size. The results showed that RA did not have a significant positive effect on hospital stay length, and there was no statistically significant difference in the efficacy between the two anesthesia methods (MD: 0.05; 95%CI: -0.38, 0.49), as shown in Fig. 6.
Adverse events
Five studies reported the impact of different anesthesia methods on intraoperative hypotension for elderly patients undergoing hip fracture surgery, involving 737 patients who received RA and 745 patients who received GA. The meta-analysis based on the random-effects model showed that RA could significantly reduce the risk of intraoperative hypotension (RR: 0.58; 95%CI: 0.39, 0.85), as depicted in Fig. 7. Additionally, the analysis of two studies suggested that RA had an advantage in reducing the risk of postoperative cognitive dysfunction (RR: 0.56; 95%CI: 0.37, 0.86). However, a similar positive effect on cognitive function was not found in the risk of intraoperative delirium (RR: 1.09; 95%CI: 0.90, 1.32). For serious adverse events, the impact of RA versus GA on postoperative mortality was not statistically significant (RR: 1.01; 95%CI: 0.81, 1.26), as shown in Fig. 8.
Fig. 7 Efficacy of RA and GA on intraoperative hypotension in elderly patients for hip fracture surgery.
Sensitivity analysis
We conducted a sensitivity analysis by excluding one study at a time to explore potential bias risks and determine the stability of the results. After excluding one study 20, the heterogeneity among the included studies decreased from 87% to 0% for surgery time. The meta-analysis based on the fixedeffect model showed that RA was related to less surgery time for elderly patients with hip fractures by approximately (RR=-2.82; 95%CI: -3.88, -1.77, Fig. 9), but its clinical effect was limited. For intraoperative hypotension, after excluding one study24, the heterogeneity among the included studies decreased from 74% to 24%, and the evaluation results based on the combined effect model indicated that RA could still significantly reduce the risk of intraoperative hypotension (RR: 0.42; 95%CI: 0.37, 0.48), as shown in Fig. 10. Additionally, the sensitivity analysis for anesthesia time, blood loss, transfusion, and hospital length did not identify significant sources of heterogeneity, and there was no change in the direction of the results, indicating that the analysis results of this study are robust.
Fig. 9 Sensitivity analysis of RA and GA on surgery time in elderly patients for hip fracture surgery.
DISCUSSION
This study included research comparing the postoperative outcomes of RA and GA in elderly patients undergoing hip fracture surgery. Using meta-analysis, we evaluated the impact of RA versus GA on surgical time, anesthesia time, blood loss, intraoperative transfusion, hospital stay length, and adverse events. A total of 14 studies involving 5,626 elderly patients who underwent hip fracture surgery were included, of which 2,768 patients received RA, and the remaining 2,858 patients received GA during surgery. The meta-analysis results showed that RA had a significant positive effect on blood loss and intraoperative hypotension but did not find that this anesthesia method significantly improved other patient outcomes.
In our study, RA was significantly associated with a reduced risk of intraoperative hypotension, possibly related to its advantage in maintaining hemodynamic stability. Hypovolemia can decrease preload, subsequently causing a reduction in cardiac output and organ perfusion. Although GA is still widely used in hip fracture surgery, various RA techniques are becoming increasingly popular. The use of SA in hip fracture surgery has increased by 50% in the past decade27. SA can reduce the body’s compensatory ability to change blood pressure, especially in patients with complex basic health status and physical weakness 28. In addition, continuous spinal anesthesia (CSA), due to its low-dose medication characteristics, has been proven to be more effective in maintaining hemodynamic stability than single-shot spinal anesthesia 29,30.
Furthermore, lower doses of spinal anesthesia, through synergistic effects with opioids, can provide effective sensory blockage while minimizing systemic effects, including hemodynamic effects 31. Multiple nerve blocks, as an alternative to spinal anesthesia, have been used to reduce the occurrence of hypotension, and some studies have reported positive effects 32,33. Based on previous research evidence, choosing the appropriate anesthesia method is of great significance for improving the postoperative outcomes of elderly patients with hip fractures. Future research should explore the specific impact of different anesthesia methods on the postoperative recovery of elderly patients and how to optimize anesthesia strategies to improve surgical safety and patient satisfaction.
Delirium is an acute neuropsychiatric syndrome commonly seen in elderly patients undergoing hip fracture surgery and is associated with increased morbidity, mortality, and medical costs 34,35. However, our study did not find a significant impact of RA and GA on the risk of postoperative delirium in patients. Although large-scale cohort studies targeting older people have shown that GA is associated with an increased risk of postoperative delirium 10, our study results are similar to previous meta-analysis results, which did not find that RA or GA affects the incidence of postoperative delirium 36,37. Delirium-related factors include age, cognitive impairment, frailty, comorbidities, surgery, and psychotropic medications, among others. Future research should further explore the efficacy differences of GA and RA in different population subgroups.
This study has the following limitations. First, eight of the 14 studies included had a sample size of less than 100 in each arm. Therefore, the results of the studies included with small sample sizes should be interpreted with caution. In addition, there is a particular risk of bias in implementing blinding and random concealment in the included studies, which may be the reason for the high heterogeneity in some of the study results. Furthermore, due to the purpose of the study, the original studies reported insufficiently on some postoperative outcomes, making it impossible for this study to conduct a quantitative evaluation.
CONCLUSION
In our study, compared with GA, RA can improve the incidence of intraoperative hypotension and reduce intraoperative blood loss in elderly patients undergoing hip fracture surgery. No significant improvement in other clinical indicators was found for RA. Due to the limitations of this study, the more comprehensive evaluation of evidence regarding RA and GA is still unclear, and more high-quality prospective studies are needed to systematically evaluate whether RA has significant clinical efficacy for elderly patients undergoing hip fracture surgery.
