Short-Acting Spinal Anesthetics for Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis.

BACKGROUND

As total hip arthroplasty (THA) and total knee arthroplasty (TKA) increasingly shift toward outpatient and short-stay care, recovery milestones such as ambulation and bladder function have become critical determinants of discharge readiness. Although spinal anesthesia is widely used in total joint arthroplasty, the relative recovery profiles of commonly used intrathecal agents remain incompletely defined.

METHODS

A systematic review and network meta-analysis were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed, Embase, Web of Science, and Scopus were searched through October 2025 for randomized and comparative studies evaluating spinal anesthetics in primary THA or TKA. Random-effects pairwise meta-analyses were performed using restricted maximum likelihood estimation with Hartung-Knapp adjustment. A frequentist network meta-analysis integrated direct and indirect comparisons among bupivacaine, mepivacaine, chloroprocaine, lidocaine, and lidocaine-based mixtures. Risk of bias was assessed using Risk of Bias 2 and Risk Of Bias In Non-randomized Studies of Interventions , and certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation. There were 16 studies encompassing 1,914 patients that met inclusion criteria.

RESULTS

In THA, short-acting spinal anesthetics were associated with a reduction in lengths of stay compared with bupivacaine (mean difference -293.8 minutes; 95% confidence interval (CI) -614.77 to 27.15; P = 0.07). In TKA, a smaller but consistent reduction in length of stay was observed (mean difference -81.6 minutes; 95% CI -167.02 to 3.79; P = 0.06). Rates of postoperative urinary retention were lower with mepivacaine and lidocaine in both THA and TKA cohorts (mepivacaine odds ratio 0.20; 95% CI, 0.09 to 0.44; P < 0.001; lidocaine odds ratio 0.51; 95% CI 0.34 to 0.77; P = 0.001). There were no significant differences observed in postoperative nausea and vomiting or readmission in either procedure. Transient neurologic symptoms were more frequent with lidocaine, but not with mepivacaine or chloroprocaine. Network meta-analysis demonstrated consistent ranking of anesthetic agents across outcomes, with mepivacaine showing the most favorable overall recovery profile.

CONCLUSIONS

Short-acting spinal anesthetics were associated with improved recovery efficiency and lower rates of postoperative urinary retention compared with bupivacaine. These findings support consideration of anesthetic duration as an important contributor to early recovery following THA and TKA within contemporary rapid-recovery pathways.

LEVEL OF EVIDENCE: Level II, systematic review and network meta-analysis.