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HSS-led Consensus Recommends Neuraxial Anesthesia for Joint Replacement

New Statement from the International Consensus on Anesthesia Related Outcomes after Surgery (ICAROS) Group

In almost all cases, regional anesthesia for both total hip arthroplasty (THA) and total knee arthroplasty (TKA) was associated with either fewer complications or equivalent complications compared with general anesthesia, according to results presented by Hospital for Special Surgery (HSS) researchers at  he 2019 ASRA Annual Meeting.

These conclusions are the result of a year-long consensus project and a final conference in December 2018 at HSS, based on meta-analyses of the published evidence examining how the type of anesthesia affects perioperative outcomes in THA and TKA.

"We recommend that regional anesthesia be used for THA and TKA when there are no contraindications or special circumstances prohibiting its use," said Stavros G Memtsoudis, MD, PhD, MBA, anesthesiologist within the Department of Anesthesiology, Critical Care & Pain Management at HSS and leader of the project and chair of the steering committee of the Anesthesia-Related Perioperative Outcomes Consensus Project.

"Millions of people annually have hip and knee arthroplasty in the world, with more than a million per year in the United States alone. There are a number of studies published suggesting regional anesthesia is beneficial, but only a minority of patients are receiving it," Dr. Memtsoudis said. "There hasn’t been a comprehensive review of the evidence and there hasn’t been a randomized controlled trial big enough to answer questions regarding outcomes definitely. We therefore felt that we needed to take on this project and provide guidance. We felt that we were the most equipped group to do so because we publish many of the population-based studies on the topic."

The steering committee convened a consensus group of 45 experts in anesthesiology and orthopedic surgery from 19 different countries to systematically analyze existing literature and produce a consensus statement. Multiple sensitivity analyses were performed to ensure data was consistent, regardless of the methodological approach used.

Consequently, Dr. Memtsoudis and colleagues conducted a systematic review according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement that included 35 randomized controlled trials and 59 observational studies.

Based on their findings, the ICAROS Group made the following recommendations:

Anesthesia Recommendation for THA:

  • Neuraxial anesthesia is recommended as the primary anesthetic technique for primary unilateral THA when there are no significant contraindications or special circumstances preventing its use. 
  • Strength of recommendation: Strong 
  • Level of evidence: Low to moderate

Results supporting recommendation:

  • Neuraxial anesthesia in total hip arthroplasty was associated with a lower risk for complications for most outcomes compared with general anesthesia. 
  • Combined neuraxial anesthesia and general anesthesia was also associated with better perioperative outcomes compared with general anesthesia alone, but the extent and range of benefits was less than the use of neuraxial anesthesia alone.

Anesthesia Recommendation for TKA:

  • Neuraxial anesthesia is recommended as the primary anesthetic technique for TKA when there are no contraindications. This recommendation is based on results showing several benefits of neuraxial anesthesia on post-TKA outcomes as well as no evidence of worse outcomes. 
  • Strength of recommendation: Weak, due to less robust evidence for TKA than THA 
  • Level of evidence: Low

Results supporting recommendation:

  • Use of neuraxial anesthesia for TKA may minimize several important outcomes, including pulmonary, thromboembolic, cardiac, and infectious complications. 
  • When neuraxial anesthesia is used, resource utilization is reduced, including ICU admission, length of hospital stay, and readmission. 
  • Neuraxial anesthesia and neuraxial anesthesia plus general anesthesia were associated with equivalent complications after TKA compared with general anesthesia. 
  • Several caveats apply to these conclusions, including that well-designed, adequately powered prospective randomized controlled trials are lacking on this subject. 
  • Data from studies of combined TKA/THA show more positive outcomes associated with neuraxial anesthesia than studies of TKA alone. A stronger positive influence of neuraxial anesthesia on THA outcomes should therefore be investigated further.

"These recommendations will help clinicians and patients choose the most evidence-based anesthesia approach to improve outcomes," said Dr. Memtsoudis. "Institutions will have to take into account their expertise and resources available, and the goal to increase use of neuraxial anesthesia in THA and TKA may be one that we’ll have to work on, as not everyone can switch immediately," Dr. Memtsoudis noted.

"This consensus is an example of what happens when you bring experts throughout the world together to achieve a common goal, and utilize cutting-edge methodology to underline the robustness of your outcomes," Dr. Memtsoudis concluded.

Members of the steering committee included: Dr. Stavros Memtsoudis (HSS), Dr. Dace Bekere (Ans. Research Volunteer), Dr. Janis Bekeris (2018-2019 HSS Perioperative Research Fellow), Dr. Crispiana Cozowicz (2015-2018 HSS Perioperative Research Fellow), George Go (HSS), Rie Goto (HSS), Mary Hargett (HSS), Bridget Jivanelli Gato (HSS), Dr. Rebecca Johnson (Mayo Clinic-MN), Dr. Jiabin Liu (HSS), Dr. Edward Mariano (Stanford-CA), Dr. Lukas Pichler (2017-2018 HSS Perioperative Research Fellow), Dr. Ellen Soffin (HSS).


Memtsoudis SG, Bekeris J, Cozowicz C, Bekere D, Liu JB, Soffin E, Johnson R, Mariano ER, Goto R, Jivanelli B, Go G, Hargett M on behalf of the ICAROS Group. “Recommendations for Anesthetic Care of Patients undergoing Primary Hip and Knee Arthroplasty: Statement from the International Consensus on Anesthesia Related Outcomes after Surgery (ICAROS) Group.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

About HSS | Hospital for Special Surgery

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 14th consecutive year), No. 2 in rheumatology by U.S. News & World Report (2023-2024), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a fourth consecutive year (2023). Founded in 1863, the Hospital has the lowest readmission rates in the nation for orthopedics, and among the lowest infection and complication rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. In addition, more than 200 HSS clinical investigators are working to improve patient outcomes through better ways to prevent, diagnose, and treat orthopedic, rheumatic and musculoskeletal diseases. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 165 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.