Functional impairment in patients undergoing major orthopaedic surgery under general anaesthesia with or without...

We evaluated whether combined general and regional anaesthesia (GA+RA) was associated with improvements in activities of daily living compared with GA alone in adult patients having major orthopaedic surgery.

This target trial emulation used data from the Japanese Diagnosis Procedure Combination system (April 1, 2016-December 31, 2023) for patients undergoing major orthopaedic surgery. The primary outcome was discharge-anchored functional change, defined as the difference in the Barthel Index scores between admission and discharge, among admissions with observed and comparable discharge Barthel Index scores. We conducted stabilised inverse probability of treatment weighting using preoperative covariates, and weighted linear regression models were fitted. Secondary outcomes included in-hospital mortality and postoperative length of stay. Missing data were handled using multiple imputations, and sensitivity analyses (inverse probability of censoring weighting, subgroup analyses, and complete case analysis) were performed.

A total of 244 212 patients received GA+RA (peripheral nerve block: 183 564; epidural anaesthesia: 60 648) and 435 462 patients received GA alone. After propensity score weighting, GA+RA yielded a higher change in Barthel Index scores (mean difference 0.73, 95% confidence interval [CI] 0.57-0.88, P<0.001), shorter postoperative length of stay (-1.40 days, 95% CI -1.45 to -1.35, P<0.001) and lower in-hospital mortality (hazard ratio 0.85, 95% CI 0.76-0.96, P=0.006). Sensitivity analyses yielded directionally consistent findings.

Combined general and regional anaesthesia was associated clinically with modest improvements in discharge-anchored functional change, postoperative stay and in-hospital mortality. Residual confounding and heterogeneity of regional anaesthesia techniques warrant cautious interpretation and prospective confirmation.