Neuraxial versus general anaesthesia in total joint arthroplasty: perioperative outcomes, selection bias and contextual decision-making: a narrative review

Abstract

Total hip and knee arthroplasty volumes are increasing worldwide and neuraxial anaesthesia is often preferred over general anaesthesia because of perceived perioperative benefits. However, much of the available evidence is derived from observational studies and may be influenced by selection bias and confounding by indication. This narrative review synthesised contemporary literature from PubMed and Google scholar up to December 2025, focusing on large cohort, registry and administrative database studies comparing the two techniques in primary THA and TKA. Across multiple datasets, neuraxial anaesthesia was associated with lower mortality, fewer complications, reduced transfusion requirements and shorter hospital stay. However, patients receiving general anaesthesia consistently had higher baseline risk profiles, including older age, higher ASA status and greater comorbidity burden, along with more frequent contraindications to neuraxial techniques. Although multivariable adjustment and propensity score matching reduced the magnitude of these differences, the overall trends favouring neuraxial anaesthesia persisted. Importantly, residual confounding from unmeasured factors such as frailty, spinal pathology and institutional practices remains a key limitation. Overall, while neuraxial anaesthesia appears to offer favourable perioperative outcomes, the evidence is largely observational and should be interpreted with caution. Anaesthetic choice should be individualised and context-specific, especially in resource-limited settings and future research should focus on randomised trials and risk-stratified decision-making approaches.