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Spinal versus general anesthesia for outpatient joint arthroplasty: can the evidence keep up with the patients?
  1. Eric S Schwenk1 and
  2. Rebecca L Johnson2
  1. 1Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  2. 2Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Eric S Schwenk, Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, USA; Eric.Schwenk{at}


Total joint arthroplasty (TJA) is transitioning to be an outpatient rather than an inpatient procedure under national and institutional pressures to increase volumes while reducing hospital costs and length of stay. Innovative surgical and anesthesia techniques have allowed for earlier ambulation and physical therapy participation, maximizing the chance that an appropriately selected patient may be discharged within a day of surgery. The choice of anesthesia type is a modifiable factor that has a major impact on both surgical outcomes and discharge readiness. Recent large database studies have provided evidence for improved outcomes, including decreased mortality, with the use of spinal anesthesia. However, few randomized, controlled trials exist and database studies have limitations. Modern general anesthesia techniques, including total intravenous anesthesia and infusions targeted to anesthetic depth, may make some of these differences insignificant, especially when newer regional anesthesia and local infiltration analgesia techniques are incorporated into TJA enhanced recovery protocols. Multimodal analgesia for all TJA patients may also help minimize differences in pain. Perhaps even more important than anesthesia technique is the proper selection of patients likely to meet the necessary milestones for early discharge. In this article, we provide two contrasting viewpoints on the optimal primary anesthetic for outpatient TJA.

  • lower extremity
  • acute pain
  • outcome assessment, health care
  • injections, spinal
  • ambulatory care

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  • Contributors Both authors contributed equally in manuscript preparation.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.