Published 12/17/2025
When treating older adults with hip fractures, choosing between general and spinal anesthesia has long been a topic of clinical discussion. A new evidence update from the Patient-Centered Outcomes Research Institute (PCORI) aligns with AAOS guidelines and provides orthopaedic surgeons with the latest research to guide these important conversations with patients and their families.
More than 300,000 older adults in the United States fracture a hip each year, with risk doubling every decade after age 50. The consequences can be devastating. Within one year of a hip fracture, half of previously independent patients either move to nursing homes or die. Given these stakes, every clinical decision matters, including the choice of anesthesia.
What the research shows
The REGAIN trial, the largest randomized, controlled trial comparing anesthesia types for hip fracture surgery, challenges previous assumptions. The PCORI-funded study involving 1,600 patients across 46 hospitals in the United States and Canada found that spinal anesthesia was not superior to general anesthesia for the primary outcome of death or inability to walk independently at 60 days after surgery.
The findings showed similar outcomes between both anesthesia types across multiple measures, including functional recovery, delirium incidence, hospital length of stay, chronic pain, and patient satisfaction. Although patients receiving spinal anesthesia experienced slightly more pain in the first 24 hours and greater prescription analgesic use at 60 days, the differences were small in magnitude.
Supporting the 2021 AAOS Guidelines
These findings reinforce the 2021 AAOS Clinical Practice Guideline for Managing Hip Fractures in Older Adults, which states that either general anesthesia or spinal anesthesia is appropriate for patients with hip fractures. This evidence-based approach empowers orthopaedic surgeons to tailor anesthesia decisions to individual patient circumstances, risk factors, and preferences.
Resources for orthopaedic practice
PCORI has developed two companion resources to support clinical decision-making. The evidence update for clinicians provides detailed study findings and clinical context, and a patient-facing version helps facilitate conversations and shared decision-making. These tools can help surgeons discuss anesthesia options, potential benefits and harms, and what patients can expect during recovery with each approach.
Access both resources at pcori.org/evidence-updates to enhance your patient discussions and ensure your practice reflects the most current evidence in hip fracture care. Additional patient education about hip fractures can be found on OrthoInfo.org.
Reference
- Cedars Sinai. Hip fracture. Fact sheet. Accessed May 9, 2025. https://www.cedars-sinai.org/health- library/diseases-and-conditions/h/hip-fracture.html